Santénet2 in Madagascar: A Personal Account


You Heard Us and Came: A Personal Look at How RTI Is Improving Health Care in Madagascar — Part 1

The following feature article is a personal account by Volkan Cakir, Santénet2 chief of party for RTI. Cakir and a Santénet2 colleague spent three days hiking through the Madagascar mountains to experience what a typical Malagasy goes through to receive access to health care. This is the first of three articles about the journey.

Volkan Cakir with participants in the Santénet2 program
Volkan Cakir with participants in the Santénet2 program

They walked in small groups, carrying luggage on their heads, babies on their backs, or bags on their shoulders. They were the people living in the remote northeast region of Madagascar. This was the sight that greeted our group of development workers as we started our three-day, 80-kilometer journey under a light and continuous rain, early on the afternoon of Friday, Sept. 7, 2012.

John Davis, the CARE/Madagascar country representative, had invited me to hike into the Malagasy bush and visit remote communities where our organizations implement health activities. Since 2008, RTI International has been implementing a community health program in Madagascar—Santénet2, funded by the U.S. Agency for International Development—along with 16 partners, including CARE. On this afternoon, we were leaving Marofinaritra, the end of the road, and starting on the trail to Maroantsetra, our destination.

The highway we were using, Route National 5A (RN5A), is part of the longer RN5, which runs from Tamatave (Madagascar's major port, also known as Toamasina) to Ambilobe, the sugar cane capital of the country. The RN5A section is not paved; only the first 20 km from each end are suitable for vehicles, while the remaining 80-km stretch—actually a narrow trail—is used as a pedestrian highway.

The view along Madagascar’s Route National 5A
The view along Madagascar’s Route National 5A

It had been unusually wet over the past few days, and the hike southwest along the river was lush with short but steep hills, darkly green and punctuated with blankets of impressionist-colored flowers of café and other tropical trees. The trail was muddy, rocky, and slippery, with the clay soil adding an extra level of difficulty. Regular travelers walk in flip flops or barefoot, genuine adepts of minimalist running and hiking. The trail was organized like any major national road, complete with greasy-spoon restaurants and simple hotels. We climbed one switchback path after another during the five hours it took to finally arrive at our first stop, Antakotako.

We were hosted by Felicienne, a community health worker (CHW) specializing in child health. She was selected by her community to provide health services, and was trained and supported by Santénet2.

Felicienne, as well as all the other CHWs who are trained and supported by Santénet2, provides preventive and case management services to the women and children in her remote community. On average, mother health CHWs serve 30 family planning clients, one-third of whom are clients less than 18 years old and another two-thirds of whom are new family planning users. Child health CHWs provide growth monitoring for an average of 30 children per month and treat an average of 10 children per month for fever, diarrhea, and pneumonia.

Malagasy people stroll through a village visited on the journey
Malagasy people stroll through a village
visited on the journey

Santénet2 uses an approach called Kaominina Mendrika Salama ("champion commune"). This intervention aims to help communities take charge of their own health while building elements of a community health system harnessed to the formal health system through three building blocks: training/supervision, information system strengthening, and a secure product supply chain. The goal is for CHWs to provide services that are community based and target the poor who do not have resources to travel to the nearest formal health facility. In addition, under this approach community leaders become responsible for ensuring that these health services are monitored at the community level—they stimulate the population's demand for health services, provide support to the CHWs, and hold the health providers (CHWs and the primary health care clinic, Centre de Santé de Base) accountable.

In the communities that we visited, we were able to view some of the achievements brought about through this community-based monitoring: widespread latrine construction, monitoring of CHW monthly reporting compliance, support for the community drug-supply point, and promotion of health-seeking behaviors for preventive mother and child health services at the community and health facility levels.

Read part two of the series here.

Read part three of the series here.

Learn more about our work in the Santénet2 project and our other projects in global health.