What We Learned from Conducting a Survey of Basic Health Services in Rural Madagascar
Access to high-quality health services is foundational to an adolescent's healthy development. Young people have a right to high-quality, holistic services—no matter their economic conditions or where they live.
Access and availability of health services is limited in rural Madagascar, although limited data exist about the issue. To better understand the landscape, Projet Jeune Leader (PJL) conducted an exploratory assessment of basic health services in our partner rural communities in Haute Matsiatra region.
Holistic Services for Adolescents in Rural Communities in Madagascar
We focused data collection on the rural communities served by the 113 "Mpanabe Jeunes Leaders" in the Haute Matsiatra region. The Mpanabe Jeunes Leaders are government teacher-trainees in public middle schools who are delivering PJL’s comprehensive sexuality education program in addition to teaching their core subject through our partnership with the Haute Matsiatra teacher training institute.
The Mpanabe Jeunes Leaders provide a package of services to young adolescents in their rural schools. One of these services is counseling: individualized, confidential listening and advising sessions. When a student shares a medical concern, the Mpanabe Jeune Leader is responsible for referring the student to the nearest public Basic Health Center (“Centre de Santé de Base”, or “CSB” in French). These centers are the entities that provide most health services in rural areas.
Contextualizing our School-Based Program in the Broader Landscape of Rural Services
The primary goal of this effort was to help the Mpanabe Jeunes Leaders learn about the services available in their nearby health center and better understand the context in which they work.
We developed a brief questionnaire to capture basic information about the availability and accessibility of health services. Each Mpanabe Jeune Leader visited their nearest health center and filled out the questionnaire with staff of the health center. Not only did this approach help us gather complete data, but provided an opportunity for relationship-building between the Mpanabe Jeune Leader—an anchor in the local school—and health center staff.
Significant Barriers to Accessing Health Services in Rural Madagascar
The data collected from 108 health centers across rural Haute Matsiatra region pointed to persistent barriers to access.
The average travel time between the public middle school and the closest health center is 32 minutes on foot. However, one-third of the health centers surveyed are located more than 40 minutes' walk from the school, up to two and a half hours of travel time in a handful of communities. These travel times make visits to a health center challenging, if not impossible, for many adolescents, and increase the risks of visiting a health center (i.e., personal safety risks of the journey).
Further adding to the challenge are limited opening hours. Only 31 of 108 health centers are open on Saturdays; only 23 on Sundays. During the school day, only a handful are open outside of typical school hours—making it nearly impossible for students to visit the health center without skipping class, especially with long travel times.
Slightly more than half (56%) of the health centers surveyed have an attending physician. The others are equipped with a mix of nurses, midwives, and/or nurse's aides, as well as volunteers and community workers. This inconsistency of human resource capacity across the surveyed region greatly reduces the range of services available to youth, and the possibility of providing high-quality, holistic, youth-friendly services.
Only 45% of health centers have services or support persons to respond to survivors of violence. While this number does represent some progress, there remains a need for greater violence response services in the health sector given the enduring prevalence of gender-based violence and violence against children.
Limited Basic Infrastructure
94% of surveyed health centers have toilets. 69% have electricity, and 68% have water. With one-third of facilities having neither electricity nor water, it is difficult to provide basic services or treatment.
Culture, Environment, and Financial Accessibility
The vast majority (89%) of the health centers surveyed do not require parental consent to accept young clients. 97% self-reported that they guarantee privacy during medical consultations.
Two-thirds of the health centers shared that they offer free or reduced-cost consultations to youth in need.
These data are encouraging. Published research and our own anecdotal experience show that the need for parental consent, lack of privacy, and cost are the most common barriers to adolescents seeking healthcare services.
In summary, we found that geographic barriers (long distances), insufficient human resources, and inadequate, basic infrastructures are challenges for health centers in the areas we looked at. Yet, there are some areas in which we see progress, notably improvements in privacy and affordability—particularly important factors for an adolescent population.
This assessment has given us more accurate and up-to-date information about the status of health services for rural adolescents. These data will inform our approach to strengthen our medical referral system and other linkages between rural service providers with the goal of ensuring every adolescent thrives and can achieve their full potential.