A coup d’état in 2009 plunged Madagascar into a protracted political crisis. Since then, USAID/Madagascar has operated under Department of State restrictions prohibiting assistance to the Government of Madagascar.   Following peaceful, transparent, free and fair elections, on May 27, 2014 the State Department lifted restrictions, clearing the way for USAID to re-engage with the Government of Madagascar.   USAID/Madagascar moved quickly to develop and implement a Mission-wide Reengagement Strategy.   

USAID officially notified all in-country partners of the removal of restrictions language from their awards; and, the Health Office issued work planning guidance to communicate priorities and align efforts relating to both the Health Implementation Plan (HIP) and reengagement. 

The Health, Population and Nutrition (HPN) Office developed the HPN Forward Project to enabled the immediate implementation of critical activities including: (1) a Commodity Supply System Review and Assessment of the national health commodity procurement and distribution system, (2) provision of technical assistance to the Government of Madagascar on health financing, namely in assisting the

Ministry of Health to develop a costed implementation plan for its new five-year health sector development strategy and to cost its Campaign to Accelerate the Reduction of Maternal Mortality in Africa (CARMMA) action plan, and (3) respond to the Ministry of Health’s request for technical assistance to strengthen leadership, management and fiscal transparency.

Simultaneously, the HPN Office began a consultative process of developing a new HPN Strategy and Results Framework, which was approved in November 2014.  The Office also completed a revised Amplified Program Description for the Strategic Objective Agreement (SOAG), which clarifies and codifies the joint USAID-Government of Madagascar health priorities, development objectives, results, illustrative activities, and responsibilities and was signed with the Ministry of Health (MOH) on September 30, 2014. 

The new HPN development objective is Sustainable Health Impacts Accelerated for the Malagasy People.  The four goals under this objective are: 

1.       Community demand and advocacy for quality health services increased

2.       Access and utilization of integrated health services increased and sustained

3.       Health system strengthened

4.       Leadership, governance and enabling environment for health sector improved

Illustrative Reengagement Activities

Immunization:  With restrictions lifted, USAID implementing partners will now focus on joint planning with health centers, including demand generation and referral for vaccination services, and will report on progress in the FY2015 PPR.   USAID partners are providing support for community mobilization for the December 2014 Polio Campaign.  In addition, through the World Health Organization (WHO), USAID is providing $500,000 to support the operations costs for the Polio Campaign. 

Stomping out polio

The Campaign for Accelerated Reduction of Maternal, newborn and Child mortality in Africa (CARMMA): The Ministry of Health launched CARMMA in early September.    The Ministry of Health has developed a roadmap focused on high-impact, evidence based interventions.   USAID/Madagascar plans to support the roadmap with the scale-up of chlorhexidine, misoprostol for the prevention of post-partum hemorrhage, and pregnancy test kits as well as the introduction of Sayana Press.  In addition, USAID provided technical assistance to the GOM to cost the roadmap. 

Ending Preventable Child and Maternal Deaths:  In June 2014, USAID organized the Acting on the Call meeting, which presented a framework for action in 24 priority countries to save the lives of 15 million children and nearly 600,000 women by 2020. Madagascar's participation in this major USAID event in Washington is of historic importance as it is the first time in over five years that the USG has been able to directly engage senior Government of Madagascar (GOM) officials in invitational travel. This meeting provided participants an incredible opportunity to network, learn, and plan how they will accelerate interventions to end preventable child and maternal deaths. UNICEF/Madagascar joined the high-level delegation.

Malagasy health delegation in front of the White House

Supply chain strengthening:   Complementing a Financial Sustainability Assessment completed by the European Union, USAID recently completed a Commodity Supply System Review and Assessment. The review was undertaken to evaluate the opportunities, issues, and challenges of delivering commodities through Madagascar’s national supply system.    The assessment looked closely at functionality and capacity of district and commune level commodity warehousing, management, and distribution to define follow-on activities. 

Health financing:  USAID provided technical assistance to the Health Sector Development Plan (2015-2019) Ministry of Health Department of Studies and Planning.  The assistance supported to cost its new five-year Health Sector Development Plan and the CARMMA action plan using the OneHealth tool. This capacity building process has helped the Ministry of Health to better understand cost drivers and determine priorities with three possible, but realistic budget scenarios.  This technical assistance will support the development of advocacy tools to assist the Ministry of Health secure funding to implement its new Health Sector Development Plan. 

Governance: As a follow-up action to the Acting on the Call event, USAID mobilized a scoping visit to provide requested technical assistance for leadership, management and governance.   The technical assistance will address key areas of management and governance, including the establishment of clear roles and responsibilities and lines of communication, strengthening the performance appraisal system, improving coordination between central and decentralized service delivery, and improved budget planning and execution. 

Human Resources for Health: Since 2000, USAID has supported the development of the community health system in Madagascar, developing a cadre of over 17,000 Community Health Volunteers to expand basic, life-saving services to the rural and remote villages where 65% of Malagasy live.   The results of a 2013 CHV Situational Assessment and the final evaluation of the bilateral project that supported the development of the cadre found that over 90% of women actually received a service from the Volunteer and that 100% of the Volunteers continued to provide services nearly one year following the end of the primary bi-lateral support project.   This has informed USAID’s decision to continue its investments at the community level, including continued provision of commodities to CHVs. 

Coming out of the June Acting on the Call event, the Ministry of Health has proposed the introduction of a new cadre of health workers to be assigned at the health center level:  Primary Healthcare Assistants will supervise the CHVs, manage health commodities, and provide some clinical services.  Seeing this as an important opportunity to further enhance the sustainability of the CHVs and support country-led planning, USAID is providing technical assistance to the Ministry of Health to design this ambitious initiative, aligning the key donors, as well as assisting with curriculum development, logistics support, and roll-out of the first phase in targeted regions. 

Towards malaria pre-elimination:  Following the lifting of USG restrictions, the President’s Malaria Initiative (PMI) developed a new malaria operational plan (MOP) with the perspective of re-engaging with the Malagasy Ministry of Health (MoH) from the central level to the primary health facility level. Planned USG support through PMI will strengthen the results already achieved by the Roll Back Malaria (RBM) partners in Madagascar towards malaria pre-elimination. In coordination with the Global Fund to fight Aids, Tuberculosis and Malaria, PMI will support malaria preventive and curative interventions including a mass distribution campaign of 10.2 million bed nets in September 2015.

Bed net distribution

USAID

 In addition, USG will support indoor residual spraying targeting over 300,000 houses in the malaria high burden east coast of the country, procurement and distribution of over two million doses for malaria preventive treatment among pregnant women, and improved malaria diagnostics and treatment through enhanced training and supervision of service providers. PMI will also support the health information system for quality malaria data to inform program management, and malaria surveillance to inform the pre-elimination activities. The next annual MOP design is scheduled for end of March 2015 and will update the needs for PMI support in consultation with the Ministry of Health and RBM partners.

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The MOH has initiated a strategic planning process in order to develop a new national health sector development plan for 2015-2019.  The five-year plan will outline consensus-driven and evidence-based priorities and objectives; it will also define expected results, strategies, and interventions to achieve the objectives.  The Ministry has already identified three Strategic Priorities:

• Prioritizing maternal and child health and strengthening the Expanded Program on Immunizatio
•  Providing high quality, integrated services to the public, especially in hard-to-reach areas
• Ensure health commodity quality and security at all health facilities