Healthy Markets CoP Session - Madagascar - July 2023

The Healthy Markets Community of Practice (HMCoP) is a group dedicated to generating awareness of market development and private sector engagement work happening in different countries and for participants to leave with a greater understanding and appreciation of the country’s health market. The speakers for the July represented FHM Engage, Madagascar Ministry of Public Health, the Association of Private Birthing Practices in Madagascar, Marie Stopes Madagascar, PSI Madagascar, The Institute of Education Technology and Management, the Federation of Mutual Health Insurance – “Miara-miahy,” and UNFPA

The July meeting of the Healthy Markets Community of Practice (HMCoP) focused on Madagascar and was the first meeting to utilize simultaneous translation. In our aim to prioritize localization, this tool facilitated participation from local actors in the country. Some speakers were also able to gather in the FHM Engage Madagascar office to present their work together, which fostered collaboration and networking. We would like to thank our FHM Engage Chief of Party for Madagascar, Sarindra Ramanitrivonony, for all her work in helping to organize this meeting. 

To start the session Kuyosh Kadirov, Health Development Officer USAID, announced he would be handing over the stewardship of the HMCoP to Senior Private Sector Advisor Andrea Bare.

Following this announcement, HMCoP Lead Facilitator and FHM Engage Chief of Party for Tanzania, Farhan Yusuf, introduced the agenda and the theme of the session around which speakers framed their presentations, namely Private Sector Contribution to Achieving Family Planning (FP) 2030 goals in Madagascar.

The next part of the meeting consisted of presentations from multiple speakers who gave rapid presentations on their work.   

Olivier LeTouze, FHM Engage Madagascar Market Description Consultant, provided context for the family planning market in Madagascar through the Madagascar Family Planning (FP) Market Description. Findings reveal that young married urban women (15-24 years old) have significant unmet need, particularly when compared to young rural women, due to: 

• An abrupt discontinuation of subsidized social marketing of FP products, which has left private sector health providers with no way to buy products.
• A lack of availability of contraceptives in the private sector. There is a concentrated supply chain with few private sector players, who are wary of the uncertain nature of the contraceptive market and therefore unwilling to commit.
• Regulations and taxes related to importing and supplying contraceptives are burdensome and difficult to understand or predict.

As efforts to support the health market have been mainly oriented towards strengthening the public sector, this has left the private for-profit sector neglected. 

Dr. Vololoniaina Rasoanandrasana, Representative of the Ministry of Public Health, shared how Madagascar plans to achieve its 2030 FP objectives (by increasing the modern contraceptive prevalence rate for married women to 60 percent, reducing the rate of unmet needs in FP to 8 percent, and reaching a total fertility rate of 3) and the 9 commitments Madagascar has made to achieve these goals and the 6 strategies for completing the commitments. Currently, the private sector is integrated into the FP technical working group and is involved in advocacy activities for resource mobilization. The private sector is also involved in the implementation of awareness-raising activities and in areas like financing where they work towards filling the gap in contraceptive products. However, more work must be done to utilize the private sector.

Oliva Harivololona, President of the Association of Private Birthing Practices in Madagascar (ASCAP), described Madagascar's private clinics (or birth centers) called “Cabinet d’accouchement,” which are run by one or more midwives and work to ensure family health through FP counseling and other services (such as pre-and post-natal consultations, screenings and treatment for sexually transmitted infections, and maternal and reproductive health services to young people). In these clinics, FP clients have demonstrated a preference for injectable and oral contraceptives. For these clients, particularly those in rural areas, access to health services is an issue, as is insufficient information, communication, and education on health.  Meanwhile, service providers struggle with quality of service and access to products. The private sector, particularly private delivery practices, need to improve services, access to services and products, and increase training to address unmet FP needs. 

Rijalalaina Rasolofonirina, Deputy Country Director Marie Stopes Madagascar (MSM) explained why FP services for youth must be addressed. First, 1 in 2 people in Madagascar is under the age of 18 – Madagascar has approximately 1.5 million adolescents –  and 81 percent live in rural areas. 496,000 of these adolescents need FP annually. 37 percent of women are married before the age of 18 and teenage fertility rates are high, and pregnancy and childbirth complications are the leading cause of death among those aged 15 to 19. The contraceptive prevalence rate is 34 percent for adolescent girls 15 to 19 years old and 42 percent for young people 15 to 24 years old. To address these factors there must be interventions designed for youth, such as:

• Multiple service delivery channels to maximize reach and target different segments with different services.
• A wide range of "connected" referral agents, from teachers to teen connectors, providing a continuum of care (from initial advice to follow-up care) via a 411-call center.
• Providers trained in the youth approach allowing adolescents to have an informed and voluntary choice in terms of contraception.
• Routine data systems, disaggregated by age, allowing adaptive and targeted interventions.
• Proposed solutions (waivers, vouchers, or free services) so that the cost is not an obstacle.

Progress remains slow due to restrictions around providing reproductive health services to minors without parental consent; a lack of accurate and comprehensive information about reproductive health and family planning; social and cultural norms; and limited resources inhibiting quality reproductive health service provision to young people. MSM is working with the private sector on: 1) integration of private providers into health insurance programs, 2) capacity building of private providers in the offering of FP services, and 3) in entrepreneurship through strengthening supply chain management to avoid stockouts. Ultimately, improving young people's access to family planning is crucial for educational, economic, and demographic benefits.

Laury Francia Rasoanirina, Program Manager PSI Madagascar described the USAID-funded ACCESS Mobile Clinic that operates across 11 regions of Madagascar. With a strategy defined by key stakeholders, USAID, and the Ministry of Public Health, the clinic has trained 20 health providers, employs 20 demand creation and service promotion agents, and collaborates with 10 regional social marketing organizations. 

Dr. Yvan Ranaivoson, Director of The Institute of Education Technology and Management (ITEM)  highlighted how the private sector in Madagascar could become more effective with greater focus on:

• Needs- understanding the quality, quantity, and condition of trainings being offered to the private sector. 
• Curriculum- focusing on the duration, subject, and the methods used to create trainings. 
• Delivery- working through the Regional Training Bureaus; how are the materials and devices used to carry out trainings.
• Evaluation and supervision- what follow up is going to be done to demonstrate the effectiveness of trainings. 

Dr. Vero Randriamalala, Representative of the Federation of Mutual Health Insurance described the “Miara-miahy” Federation. This non-profit umbrella organization was started in 2019 and has nine active member mutuelles – a type of nonprofit insurance arrangement – in 22 regions across Madagascar to facilitate access to quality and affordable care for the entire population. They offer 15 types of services, including primary care, childbirth, family planning, and preventive health. The organization is looking to increase awareness of FP by identifying NGO partners for sexual and reproductive health (SRH)/FP to alleviate the expenses of the mutual funds. The most recent results show that 715,326 people were covered by mutuals at the end of June 2023, 65 percent of members are women, 60 percent of members are of childbearing age, and 50 percent are young couples. Despite this success, there are problems that still need to be addressed like unavailability of FP products for certain areas, psycho-social barriers (e.g., a husband's reluctance to use FP, culture, etc.), and limited funding for mutuals to intervene in isolated areas. 

Faly Razanalison, Sexual Reproductive Health and Rights (SRHR)/FP Program Specialist UNFPA Madagascar capped off the presentations by explaining how UNFPA offers technical support in Madagascar through 1) advocacy, policy, dialogue, and support; 2) knowledge management; 3) capacity development; 4) provision of services; and 5) coordination, partnership, and cooperation.  From 2022-2023, UNFPA worked on: 

• Strengthening the supply chain.
• Enhancing the availability of methods and choices.
• Mobilizing sustainable funding for FP from domestic or other sources.
• Increasing availability and access by women and girls in the most isolated regions through seed funds.
• Increasing storage and distribution of reproductive health (RH)/FP products including at last mile distribution points in 23 regions.
• Strengthening public-private partnerships to use drones for last mile distribution.
• Training health workers. 
• Providing technical assistance through third-party procurement with World Bank funding for the purchase of FP products with the UNFPA procurement platform. 

UNFPA is also utilizing mobile clinics, provides youth services including comprehensive sex education and peer education, and a midwife program that offers support for training. UNFPA demonstrates how multiple approaches are needed to reach Madagascar’s FP 2030 goals. 

To end, we extend a great thanks to all who participated in this session on Madagascar, particularly those that took the time to speak and prepare slides. As we did not have enough time to fully explore all of the topics that were presented, the HMCoP is considering holding a follow-up session on Madagascar. Please contact Andrea Bare (abare@usaid.gov) or Jessica Jones (jjones@chemonics.com) if you are interested in participating in this event.

Overall, we are excited that there was such a positive response to this meeting. We were pleased to see that speakers were so passionate about their topics, that HMCoP participation remains high, and that members continue to thoughtfully engage in these meetings every month. We hope that organizations continue to share the progress of their work so that we may continue to facilitate this collective learning and look forward to continued participation in future sessions. 

Resources

We are interested in hearing from those of you that have been engaged in the HMCoP. Please use this survey as an opportunity to let us know your thoughts and if there are any changes you would like to see. 

Future Meetings

The next HMCoP country of focus will be Liberia and is scheduled for August 30th. If you would like to take part in or contribute to this session, please email Elizabeth Peña at (epena@FHM-Engage.org) or Farhan Yusuf (fyusuf@FHM-Engage.org).

Questions?

Please email Jessica Jones (jjones@chemonics.com) or Elizabeth Peña (epena@FHM-Engage.org).