Voices from the Village: Improving Lives through CARE's Sexual and Reproductive Health Programs - Going the Extra Mile to Provide and Sustain Family Planning Services in Remote Madagascar

This 12-page case study documents a 2-year initiative undertaken by CARE in Madagascar (at the behest of the United States Agency for International Development, or USAID) that was designed to bring education and family planning (FP) services to remote communes in Madagascar located in conservation zones that are threatened by the growing population. Launched in 2005, the Extra Mile Initiative (EMI) expanded upon activities aimed at increasing awareness of and access to FP services through a combination of community planning, identification of the economically poorest families not able to utilise existing FP support, expansion of existing community-based distribution schemes, person-to-person training, and information, education, and communication (IEC) materials. This publication explores how the EMI was embedded in the local health system, communities, and local government of the communes it served - providing a network of people and institutions to continue to meet the FP needs of the population after the project ended.

According to this report, when the EMI began, the contraceptive prevalence rate there was about 11% (traditional and modern methods combined), which is well below the national average of 27%. Twelve months later, 24% of women of reproductive age (WRA) in the project area were using some method to plan their families. This report seeks to answer the question: How was the EMI so successful in such a short time? In both baseline and midterm evaluations, interviews were completed with 416 households. In 2005, 638 men and women of reproductive age were surveyed; in 2006 the total surveyed was 817. A final evaluation report is expected.

Excerpts from the report follow:

"After only one year of EMI activities, the baseline contraceptive prevalence rate of 11 percent more than doubled...

People's knowledge of methods has also grown. The baseline survey showed that approximately 74 percent of women and 61 percent of men had heard of at least one way, modern or traditional, to prevent pregnancy. By mid-term, knowledge of at least one method had risen to 83 percent among women and 74 percent among men. This rise is due in large part to the extensive network of EMI-trained CHAs [community health agents] and other volunteers who are active in their communities....[A] CHA in Ambahoabe, says, 'Before EMI, even I didn’t know about family planning. Only the doctor did, and communities learned about it only by accident ? for example, if a woman fell ill and the doctor prescribed a contraceptive so she wouldn’t become pregnant while recovering.'

The EMI has greatly increased the channels for spreading information on family planning....[A] member of Miaradia, one of dozens of civic groups that participate in the project [said,] 'Our messages and songs clearly state the different methods and where to get them....If a man or woman asks, we send them to the nearest CHA, or to the health center if they want injectables.'

When the EMI began, the prevailing notion was that the topic of health (and thus family planning) 'belonged' to the health center, and was only nominally the business of local government. Over time, however, this view has shifted radically....[The] mayor of Fotsialanana [said], 'We can really define family planning as life planning. It is therefore the responsibility of all development actors...'

[Amongst the challenges faced was related to the remoteness of 6 communes served]....For one, communities had far fewer sources of information about family planning than their more urban counterparts, and this meant that misinformation and rumors thrived. And without guidance, training or support, local structures such as SDCs were largely non-functioning. Furthermore, while health staff reported up the Ministry of Health chain of command, they had little wherewithal to reach out to communities and local leaders.

Yet the project area's remoteness did serve the EMI well in one fundamental way: The communes were eager to participate in a development project, to learn new things and to take action to improve their well being. In roadless Ambahoabe commune, for example, the SDC organized residents of the commune seat to smooth out nearly five miles of trail so that field agent Sebastian Boutobé could reach them by motorcycle, rather than on foot. Today, Sebastian laughs as he recalls how his motorcycle was the first ever seen in town...

What CARE Has Learned:

• The triad of project responsibility was crucial to success, perhaps especially so in remote areas: Embedding the EMI in three entities ? the health system, the community (via volunteers) and the SDC ? provided a sturdy and integrated foundation. While the EMI guided activities and devoted substantial effort to building capacity within each part of the triad, CARE itself was not responsible for making decisions, hammering out negotiations or clarifying responsibilities....[N]ow that the members of each commune's triad have a clear understanding of one another’s roles and responsibilities, and two years' experience jointly planning and implementing all manner of activities related to family planning and health, they are poised to continue this work after the EMI formally ends...
• The principles of good governance created space for dialogue and collaboration where none previously existed:...In Ambahoabe, Dr. Florentine Baozoma speculates on what her health outreach work would be without the collaboration of the SDC. 'In everything I do, every activity, I ask their advice and their support,' she says....Deputy Mayor Robert Bezafy concurs. 'Before the EMI, we did communicate, but now the collaboration is much better,' he says. 'We can’t leave [the work] only to the doctor and the CHAs. We must support them. We meet before every set of activities to define roles and responsibilities, and this holds for all health matters, not only family planning.'....CHA Eliette Razafy reflects on the interdependency of the players...'[W]ithout CHAs, there would have been no increase in the number of women who use family planning. The doctor simply does not have the time to travel around and do all the education that we do.
• Senior CHAs headed a strong, diverse network of volunteers...
• EMI has contributed to rising health factors (not only family planning knowledge and use)..."

Click here to access the full report in PDF format. Note: Please contact Brooke Barnes at bbar@care.org if you would like to request hard copies. Also, this document will be in available in French soon.