Creating access to care in Madagascar

In 2009, the first project supported by the World Diabetes Foundation in the island state of Madagascar saw the light of day. However, as the project started the country experienced a political upheaval leaving the health authorities a bit on the sideline.

15 May 2012 Brit Larsen

Access to care outside Madagascar's capital, Antananarivo, is an enormous challenge for people with diabetes. Sometimes, people travel several hundred kilometres to get medication (Photo: Ulrik Uldall Nielsen)

Fortunately, the Madagascan Diabetes Association (A.MA.DIA.) which has a committed staff ensures that people with diabetes in Madagascar get the best possible care and treatment under extremely challenging conditions. A.MA.DIA. is fully recognised by the official health authorities to conduct diabetes care and treatment, and its consultations cover nearly 1,500 people with diabetes every month at its Antananarivo headquarters. A.MA.DIA. employs an approach which is both innovative and unique for the region and with funding support from the World Diabetes Foundation, their services will now be expanded to other parts of the island nation.

A perfectly normal life
Ms. Laurette Volonona is a retired high school teacher aged 56. She lives with her husband in Ambositra, 90 km south Madagascar's second biggest city, Antsirabé. In 2007, she was diagnosed with diabetes and has attended a monthly outreach clinic organised by A.MA.DIA. since. "My mother had diabetes, so when I first got the results from the tests, it did not really come a surprise. Of course, I was sad because it is a chronic condition, but it was fully expected," she says. At the monthly outreach clinic she buys her medication and she attends educational sessions. "With A.MA.DIA. there is a certain climate of familiarity and equality between the doctor and the attendants. This is reassuring because it makes us feel like everybody else and that we can live perfectly normal lives as long as we control our diabetes. Personally, this relationship and positive environment is what makes me come back every month for the education sessions," she says.

The diseased is king
Ranked number 135 out of 169 countries on the 2010 Human Development Index, Madagascar is categorised as a country of medium human development. However, judging from Ms. Volonona's statement, the atmosphere and services rendered by A.MA.DIA. do not resemble anything of medium level. Rather, the level of knowledge about diabetes among the patients is surprisingly high.

Dr. Pierre Ratsimbazafy attends 400 regular patients on his own as he is the only person working in the clinic in Antsirabé. While this may seem an almost insurmountable task, Dr. Pierre's approach enables patients to deal actively with their condition almost irrespective of their economic situation.

"When I first started working in this area, someone wrote a parable which translates into ‘the diseased is the king.' It means that the centre of attention is the patient - an approach which breaks the classical perception of the doctor sitting on his throne giving orders to his subjects. I as a doctor am only one of the many people around the patient who enable him or her to live with a chronic condition," he says.

He continues, "Since then I have developed my interpersonal communication to provide therapeutic education for the person with diabetes and his or her circle of friends and family. Over the years, the work has turned out to be fruitful in terms of measuring results; we see that the patients in our centres manage their diabetes increasingly better taking their level and individual point of departure into consideration. What happens is that they are being pushed to participate actively in their new life."

The art of therapy in Madagascar
The approach used by Dr, Pierre and by his colleagues in A.MA.DIA. is named "art therapy" and it emanates from the Swiss-based Fondens Foundation and Prof. Jean-Philippe Assal. Art therapy is about getting patients to express themselves on topics somehow related to their diabetes, acceptance of the condition, relation between patient and health care provider. The art therapy is organised as a workshop and can include various activities such as role plays, building a totem, drawing or painting.

During his recent visit to Madagascar, Programme Coordinator of the World Diabetes Foundation, Mr. Ulrik Uldall Nielsen was presented with the concept of art therapy and also met the knowledgeable patients at the Antsirabé clinic: "Looking at the projects supported by the World Diabetes Foundation in other settings of similar challenges, this specific approach is an innovative and different way of conducting patient education. It has a great impact on people in terms of accepting that they have a chronic disease, in this case diabetes. I believe it could be worthwhile to apply this approach in some of our other projects. No matter the economic situation, family support and self-recognition are universal factors for living better with diabetes," he says.

Expanding to 15 clinics
Back in the capital of Antananarivo, A.MA.DIA.'s medical clinic has 20 beds for in-patient treatment, a dispensary for out-patients as well as six decentralised units spread throughout the country. During the project supported by the World Diabetes Foundation which runs from 2009 to 2014, the purpose is to strengthen A.MA.DIA. as an organisation to be able to develop its services for people with diabetes, in quantity, quality and geographic extent, and to create an exemplary reference. This entails training of health care personnel, including doctors, nurses and diabetes instructors to be able to manage the diabetes clinics outside the capital. In addition to the existing clinics, under the supported project another nine clinics will be established to a total of 15 clinics.

Avoiding parallel structures

As mentioned initially, due to the current political situation in Madagascar, direct action on health issues is left to the initiatives of donors or private organisations. Mr. Ulrik Uldall Nielsen admits that under normal circumstances not supporting the public structures does create parallel structures: "On the other hand, for diabetes care," he says "this is currently all there is, so in reality this is the existing system as nothing exists within the public system . Although the Foundation does not want to create parallel structures by working outside the public health authorities, in the case of Madagascar it is the only feasible thing to do. We collaborate with an NGO (A.MA.DIA.) and this is the most sustainable entity to work with in the political void currently permeating the country. The situation may change and at that moment we will of course be willing to adjust with the aim of ensuring local ownership and sustainability of the work we support.

We are assured that A.MA.DIA. is fully recognised by the health officials and we already see examples of collaboration. For example, some of the A.MA.DIA. clinics have been established inside the public health facilities," he says.

Deficient insulin supply

While A.MA.DIA.'s staff members offer high-quality services, access and availability of insulin remains a permanent problem, particularly outside the capital, Antananarivo. It is commonly known that insulin is scarcely available in the public as well as in the private supply system even though insulin is on the essential drugs list. A.MA.DIA. purchases insulin at central level and ensures medicine to all their members.

While doctors such as Dr. Pierre do their utmost to reach remote areas through weekly outreach clinics, the reality for some patients is long travels to purchase insulin from the A.MA.DIA. clinics.

After the monitoring visit conducted by the World Diabetes Foundation in January, the Ministry of Health has accepted to allocate funds for insulin and syringes. Furthermore, A.MA.DIA. and the Ministry of Health are establishing contacts with pharmaceutical companies to improve the availability of insulin.

Help to children with diabetes

During his visit in Antsirabé, Mr. Ulrik Uldall Nielsen witnessed one of the devastating consequences of the deficient insulin supply. At the A.MA.DIA. clinic, a rather high rate of type 1 diabetes patients attend the clinic; three-quarters of these are children or adolescents. Sadly, most of them die within few years due to lack of access to insulin. Following these observations, the Foundation is now establishing a fundraiser programme to provide basic medical requirements and follow-up to children whose parents cannot afford it. The programme will be run in collaboration with A.MA.DIA. and will initially support some 30 children. The children will be provided with strips, insulin and syringes, lancets, HbA1c measurements and home visits. The annual cost per child is not yet known but expected to be in the range of similar programmes for children's in Kenya and Tanzania.

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