By Dr Vik Mohan, Medical Director, UK
I recently spent a hectic and intense couple of weeks in the village of Andavadoaka, the village where our community health programme is based, during my annual visit to Madagascar. Although I founded this initiative several years ago, each return trip brings new and inspiring stories and lessons from our team on the ground.
This particular visit was quite eventful, to say the least. We celebrated the fifth anniversary of the launch of our community health activities; held the inauguration of our new health clinic and environmental education buildings; opened the doors to our very first antenatal clinic in the region; facilitated a Community-Led Total Sanitation (CLTS) mobilisation in Andavadoaka; hosted a successful visit from our partner Marie Stopes Madagascar; trained all 30 of our Community-Based Distributors (CBDs) in how to counsel women on the use of Long-Acting Reversible Contraceptives (LARCs); and visited some of the poorest and most isolated communities we serve in the neighbouring Mikea forest.
As someone who spends much of my time working remotely, away from our field site, it was incredibly valuable and rewarding to see our programme in action. No words can quite explain the joy of witnessing the value of our work firsthand: watching a pregnant woman get the opportunity to receive antenatal care for the first time, or a young mother make an informed choice about how long she wants to wait before she has another baby; appreciating the gratitude that people feel because we’ve taken the trouble to provide services to their remote community; and having the regional Medical Inspector join us as we dance to a song that was written and performed by our CBDs.
One thing that hasn’t changed over the years is transport; it sure doesn’t get any easier! Our home base, Andavadoaka, is eight hours travel across sand and through the spiny forest in a 4×4 from Toliara, the closest big town. To get from Andavadoaka to the Mikea is even harder as the sand is too deep for our 4×4 to manage. In order to visit some of the forest communities there, Caroline, our Safidy programme coordinator, and I took a cart pulled by zebu (local cattle) for two hours to Befandefa, another village, then walked four hours in deep hot sand to get to the first village in the forest, Ankililaly. The following day was just as strenuous: seven hours in a zebu cart travelling between villages and finally back to Andavadoaka. It was worth the effort, though. The reception we received from Ravao, the lovely CBD in Ankililaly, moved myself and Caroline to tears. She gave up her hut for us to sleep in, made us dinner, sang and danced for us with her family by moonlight, and tried to give us one of her precious chickens as a gift to say thank you for coming to visit. These Mikea forest communities are some of the poorest I’ve ever met, and I felt humbled by their generosity.
Ravao’s story is truly amazing. She’s about 40 years old and has 12 children; the oldest is 24, the youngest is 2. Until we introduced the community health programme in Ankililaly, Ravao had no access to family planning. As soon as our services reached her village, however, she started using them and is now a regular client. When we were recruiting women to become CBDs, she felt so strongly that women in her region should have access to contraceptive options that she volunteered herself. Being an intelligent and highly respected member of her community (and one of only a few literate women in the region), she was an obvious candidate for this role.
Now fully trained, Ravao is a tireless champion for women’s reproductive rights, using her knowledge of the people of the Mikea and their semi-nomadic lifestyle to reach as many couples as possible with much-needed family planning services and health education. She walks over five hours to Andavadoaka to attend any training sessions that we offer, such as the quarterly reviews for our CBDs, and is grateful for the opportunity to develop her experience and skills. Her commitment to her work, and the fact that she is part of and has the full respect of her village, makes her more effective at providing these services to this community than any of us from the outside could ever be.
It has been great to witness the impact of our work. I get a definite sense that people understand issues relating to health and sanitation far better than they did at the launch of the programme 5 years ago, and its link to the environment and their livelihoods. While it is difficult to quantify, it seems that the women I met were more empowered, and more active in making decisions about their health and engaging in livelihood activities. The proportion of women using contraceptives has increased fourfold since we started the programme, and we have witnessed a significant reduction in the general fertility rate as a result. Quite apart from the huge health and social benefits that this brings, it’s also worth noting that the population of the region would be higher than it is now if we were not providing these services. This slowing in population growth has the added benefits of increasing community resilience, as well as improving food security and supporting local conservation efforts by decreasing pressure on natural resources. I feel so excited to know that our work impacts so positively on Ravao and the thousands of women like her living in this isolated and under-served part of Madagascar.