Primary care at the last mile in Madagascar
Primary care encompasses the essential frontline services everybody needs. In Madagascar, it covers the majority of health issues people are likely to encounter, from infectious diseases and malnutrition to common drivers of child and maternal mortality. PIVOT has been working in the country since 2014 to transform the public health system in a single rural district of approximately 200,000 people into an evidence-based model of universal health coverage that can be sustained, replicated, and scaled nationally. PIVOT delivers high-quality primary care in health centres, ensuring all facilities are staffed and equipped. With more than 70% of the population living more than a 5-kilometre walk from the nearest health facility, PIVOT supports reliable community-level health services through a network of professionalised community health workers who proactively bring care to the patient’s door. PIVOT also provides comprehensive support to Ifanadiana District’s public hospital. We’re supporting PIVOT’s expansion plan to achieve full primary healthcare coverage in the Ifanadiana District by 2022.
Madagascar is one of the poorest countries in the world with one of the weakest health systems. Of the nation’s 24.9 million people, 72% live in extreme poverty and almost one in every two children under five years of age suffers from stunting due to malnutrition – the world’s fourth highest rate. On average, 1 in 7 children die before the age of 5.
Madagascar is divided into 114 government districts. Each district, at least on paper, offers the main pillars of the public health system, including a hospital to serve the district population, health centres in each commune, and a network of community health workers who provide basic care in their home villages.
At the invitation of Madagascar’s government, PIVOT has been working alongside the Ministry of Public Health since 2014 to transform the health system in a single rural district – Ifanadiana – into a model of universal health coverage that can be sustained, replicated, and scaled nationally. Located eleven hours from the country’s capital in southeastern Madagascar, Ifanadiana District is home to nearly 200,000 people.
One of PIVOT’s current priorities is extending access to primary care and community-based health services to the remote areas of the district that their clinical and operational support services have not yet reached.
PIVOT addresses a range of the population’s most urgent health needs at community, health centre, and district hospital levels, prioritising childhood health, infectious disease, and maternal and reproductive health. It does so by:
- renovating health facilities for the delivery of high-quality, dignified care;
- staffing and equipping facilities to Ministry standards or higher;
- ensuring strong supply chains and the availability of biomedical services;
- and building capacity among staff – from cleaners to doctors and community health workers.
PIVOT underpins this model of public healthcare delivery with robust, deeply embedded, highly usable data systems and rigorous, multidisciplinary scientific research. Both serve to drive programmatic efficiency and ensure the patient population’s needs are prioritised depending on their urgency, not their distance from care.
We’re supporting PIVOT’s expansion plan to achieve full primary healthcare coverage in the Ifanadiana district by 2022. This entails renovating, staffing and equipping 22 health facilities and training and professionalising 705 community health workers, while simultaneously strengthening their data integration.
PIVOT plans to achieve full coverage of the district by 2022, establishing an evidence-based model of accessible, reliable and effective health services that can inform Madagascar’s national health strategy and generate lessons for the replication and scale of the district-level model nationally.