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Madagascar's health challenges

2015; Elsevier BV; Volume: 386; Issue: 9995 Linguagem: Inglês

10.1016/s0140-6736(15)61526-4

1474-547X

Sima Barmania,

Global Health and Epidemiology

Madagascar is still recovering from a 2009 political coup, and faces new political difficulties as it attempts to tackle its myriad health problems. Sima Barmania reports. The past couple of months have been politically difficult for Madagascar. The country's president, Hery Rajaonarimampianina, elected in 2013, has survived impeachment by his parliament for alleged constitutional violations and incompetence after challenging the claims in court. But the events are raising questions over the country's already fragile political stability. Madagascar, the fourth largest island in the world with a population of 22 million, is still recovering from a coup in 2009, which overthrew then President Marc Ravalomanana. In June, the World Bank decreased its 2015 growth forecast for the island because of severe weather events earlier in the year and a mining slowdown, noting the longer term outlook could be affected if the country's political problems persist. The 2009 political crisis had a substantial impact on the country's health sector, from budget cuts to donor withdrawal. Jean-Claude Mubalama, a health specialist at UNICEF, said: “It's clear that since the crisis, the budget allocated to the health sector has decreased.” This shortfall, he explained, had a bearing on the ground with the departure from rural areas of many health-care workers who had not been paid. Some left to work for non-governmental organisations, others headed to the capital Antananarivo in search of work. It is an observation shared by many, including those within the country's Ministry of Health, such as technical specialist Felix Andrianjaranasolo. He states that after 2009, aside from problems with funding, there “were many changes, new ministers and no stability” within the Ministry. But he said that the main health issue now is the scarcity and distribution of human resources. At the most, a town in Antananarivo would have “12 doctors but in more remote areas there is often only one health-care professional and often not even a doctor, maybe just a midwife”, said Andrianjaranasolo. As a result, there has been a decline in health outcomes, explained Mubalama: “Many of the indicators have been stagnating. In terms of mother and child health, the number of skilled birth attendants decreased during this [politically uncertain] period.” In addition, Mubalama said that immunisation coverage had decreased. Polio, which had been eliminated, has also returned, and the number of cases of malaria has risen, even in Antananarivo where malaria had not been previously reported. Malaria is a pressing concern, especially in coastal areas, with the weather acting as both a catalyst and a buffer, explained Herlyne Ramihantaniarivo, the director general of the Ministry of Health: “After the floods [in February and March], there was stagnated water, which supports the mosquitoes, but now winter is helping us.” Mosquito bednets have been provided as a prevention strategy but the nets were often used for fishing, which some communities saw as more of a priority. “It is unacceptable to have boys and girls dying from malaria”, said Charlotte Ndiaye, the WHO country representative. She believes that there is a need to sensitise communities, undertake rapid diagnostic tests, and provide malaria chemoprevention during the rainy season. In addition, Ndiaye is worried by the existence of bubonic plague in Madagascar, a disease with high lethality. Plague is endemic on the island, where outbreaks have resurfaced nearly every year since 1980, according to WHO. During the past 3 years, the annual number of cases has steadily increased, making Madagascar the country most severely affected by plague worldwide. “Last year, there were many cases of plague associated with the rats that proliferate after forest burning”, said Ramihantaniarivo. Tuberculosis is also a concern despite support from donors to combat it. Many people find it difficult to access health care despite it being free of charge; 40% of the population live in areas far from health centres. “Madagascar is a huge country and we don't have the infrastructure to reach the villages”, said Ramihantaniarivo. People often have to choose between walking for 2 hours to get to a health centre or going to work, she added. The vastness of the landscape as well as environmental factors pose an extra challenge, said Simeon Nanama, a nutrition specialist at UNICEF. This is a “country of contrasting situations, floods in Antananarivo but drought in the south”. Nanama said that undernutrition is a huge problem in Madagascar because of poverty and issues such as drought. The country is ranked fourth in the world for chronic undernutrition, according to UNICEF, with around 2 million children affected, almost half younger than 5 years. It also has the fourth highest stunting rate in the world, said Nanama. Nevertheless, Nanama is prompt to clarify that undernutrition is not only an issue of food scarcity but also of factors such as water and sanitation. Contamination of water with faeces can lead to illnesses, diminishing absorption of nutrients. Sanctions were imposed on the country after the coup; however, some donors found a way to circumvent these constraints by partnering with non-governmental organisations and this was “critical in maintaining some of the [good] indicators”, said Nanama. “It could have been worse.” Another cause for optimism is Madagascar's low rates of HIV. The country has the lowest prevalence of HIV in the whole of sub-Saharan Africa (under 0·5%). “Madagascar is an isolated island separated by the sea and this may have a protective effect”, explained Clarimond Raveloson from UNAIDS. It also has high rates of male circumcision, which would also contribute to the low HIV rates, he said. However, Raveloson is vigilant over the potential for HIV to increase; many people are afraid to get tested, he noted. “HIV in Madagascar is not visible and we want to make it visible.” It's an issue that local non-governmental organisation, Action Socio-Sanitaire Organisation Secours (ASOS), has been engaging with, said executive secretary, Jean Claude Rakotomalala. ASOS has been recruiting young people in the community, aged 15–24 years, to act as peer educators on the prevention of HIV, encouraging testing and use of condoms. ASOS works with the local community to support health-care workers who provide both health information as well as providing medicines for malaria and pneumonia. As part of their health communication strategy, they use traditional folk dance, songs, theatre, and puppets to provide health messages about malaria and other diseases. “It's good for sensitisation”, said Rakotomalala, because it is attractive for children and for adults, especially given that the accessibility to media and education is poor. Madagascar has a mix of highlands, arid deserts, thick forests, and coastal areas, and roads are scarce or of poor quality. Navigating the large and rural terrain requires creativity and innovative partnerships, often with those in other sectors, such as conservationists who safeguard Madagascar's unique array of animal and plant species. Conservationists are often accustomed to working in remote areas and can aid in logistics, explained Caroline Savitzky, population, health, and environment coordinator at Blue Ventures. Blue Ventures’ mandate is to protect the natural marine biodiversity of Madagascar and rebuild tropical fisheries with local communities but the organisation discovered it could also contribute to other areas of need, such as health care. Savitzky explained that although there is greater appreciation of the complex interplay between the environment and health, the onus tends to be on how the environment affects human health, such as natural disasters; there is a failure to recognise that human survival can put pressure on the ecosystem, which in turn has a negative affect on human health. The population, health, and environmental approach that Blue Ventures champions, recognises these connections. The organisation has incorporated reproductive health services into its fisheries management initiatives since 2007. The programme now serves a total of 20 000 people across 50 villages in Madagascar. Despite these collaborative efforts, WHO's Ndiaye is concerned about the lack of international attention the country receives. “Madagascar has been completely forgotten by everyone”, she said. But she hopes that the country's ongoing efforts to achieve universal health coverage will have strong results, including the availability of health services at the district and community level and improved access to essential medicines. In the interim, the political situation and health needs make the country's challenges substantial. It is therefore vital “to give a voice to Madagascar”, said Ndiaye.