Eradicating fistula in Madagascar
In 2018, we supported Operation Fistula in Madagascar to pilot a programme which aims to identify and treat women suffering from obstetric fistula in the Sava region of Madagascar. The pilot phase enabled 50 women to be treated for this devastating condition through a promising pay-for-performance clinical model that should be associated with a community mobilisation model.
Obstetric fistula is a devastating condition that the Institute for Health Metrics and Evaluation ranks among the world’s highest-burden disabilities and compares to having both legs amputated. Women who experience it suffer from incontinence, health problems and strong social stigma. And yet a surgical procedure to treat it effectively exists. What’s more, it only costs a few hundred dollars. But 99% of the one million women in Africa and South Asia living with fistula don’t have access to this treatment.
During this phase it proved essential to:
- Obtain an extensive understanding of the barriers women face to accessing care
- Finalise the protocols for operative and post-operative nursing
- Establish a pay-for-performance funding system that only pays surgeons when they treat patients successfully and pays them directly, thus driving quality and delivering unprecedented cost-effectiveness
By the end of the year, 49 women had been treated, considerably less than the 120 anticipated, as a result of the following:
- All 49 of the surgical procedures were performed at the Sambava Regional Hospital, where the clinical model is now established and a clinical team fully functional
- Operations couldn’t be launched as planned in three other district hospitals due to a lack of operating tables and fistula repair kits
- The low number of patients identified and treated was also due to a number of challenges and bottlenecks to patient mobilisation, including the presidential elections and approach of the rainy season and vanilla harvest, which led to a significant deterioration in security in the region, reducing the willingness of patients to travel
Overall, this first year of the programme confirmed the success of the clinical model and brought an important lesson, namely that the success of the community model - in which all activities happen outside the clinical setting - depends almost entirely on being able to identify patients and mobilize them effectively to seek out diagnosis and treatment. Deeper community reach and a greater presence on the ground - both planned for the coming year - will help achieve this, fostering trust and instilling confidence that the treatment offered is free and accessible.