Technical Brief: USAID Community Capacity for Health Programme – A Bicycle Micro-Enterprise Approach to Improving Community Health Worker Mobility and Motivation in Rural Madagascar

In much of rural Madagascar – where over 60 percent of the population lives – a lack of access to affordable and reliable transport hinders uptake of health services. Community Health Volunteers (CHVs) are essential in health service delivery and have key roles in implementing the country’s strategy to achieve universal health coverage. Despite this though, they do not receive a salary from the government and face the same transport barriers affecting rural communities.

Transaid has been an instrumental programme partner in the establishment of “enterprise box” or eBox initiative, as part of Mahefa Miaraka’s broader integrated approach to address transport-related barriers to accessing healthcare. The eBoxes are bicycle sale and repair micro-enterprises managed by registered cooperatives that aim to overcome some of the transportation barriers face by the local population.

The eBox incentivises the ongoing participation of cooperative members through income-generating activities (IGA) and provides strategic support to other integrated transport activities including providing bicycles to selected CHVs to improve their ability to travel, maintaining local bicycle-ambulances, and increasing transportation options for the local community. The profit generated by the cooperatives also provides support to local health insurance schemes (mutuelles de santé and caisse santé) that reimburse participating community members for medical costs incurred at local health centres.

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Technical Brief: USAID Community Capacity for Health Program – Community-Led Transport Solutions Improve Access to Health Care

In Madagascar, the mortality rates for mothers and children under five (CU5) were 335 and 51 per 100,000 in 2019, respectively. Delays in seeking access to quality care are a key contributor to maternal and under-five mortality. Inadequate access to transport has been identified as one of the three major reasons for delays in access to health services, and can worsen the clinical severity of cases, especially when complications exist.

In a context where the availability of transport is often low, the cost of emergency transport is frequently a major barrier. Moreover, difficult terrain and seasonal rainfall often limit access by motorized vehicles to many areas. In areas supported by the USAID Community Capacity for Health program, 44 percent of communities were inaccessible by car or truck for at least four months of the year and 20 percent were inaccessible for almost half the year.

Maximizing the potential for communities to develop and manage their own emergency transport schemes has been shown to be an effective method of increasing access to health care by drawing on available community resources.

Transaid has been instrumental as a key programme partner in the establishment of the community based transport solutions, bringing over a decade of practical experience in operating similar models across sub-Saharan Africa. As always, large focus was given to the sustainability and embedment of such models within the communities they serve.

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Manual: eBox Management Guidelines (Malagasy)

The USAID Community Capacity for Health program is an integrated community health program funded by USAID for five years (June 2016- June 2021). The program, Mahefa Miaraka, is implemented by JSI Research & Training Institute, Inc., in partnership with FHI 360, Transaid, and Action Socio-Organization Secours (ASOS), and in close collaboration with the Ministry of Public Health.

The eBox initiative follows a social enterprise approach and generates income as a bicycle workshop which sells and repairs second-hand bicycles. The eBoxes were introduced to respond to gaps in the bicycle sales and repairs market, and focus on building local skills amongst community members to ensure a long lasting impact.

This ‘Complete Simplified Manual’ has been developed to provide guidance to all those associated with managing and operating the eBox. It provides information on the roles and responsibilities of those associated with the eBox including the Board of Directors and eBox staff. An abridged version of this manual is also available, which focuses on essential tasks for eBox staff members.

Click below to download the full manuals in Malagasy.

Manual: eBox Management Guidelines

The USAID Community Capacity for Health program is an integrated community health program funded by USAID for five years (June 2016- June 2021). The program, Mahefa Miaraka, is implemented by JSI Research & Training Institute, Inc., in partnership with FHI 360, Transaid, and Action Socio-Organization Secours (ASOS), and in close collaboration with the Ministry of Public Health.

The eBox initiative follows a social enterprise approach and generates income as a bicycle workshop which sells and repairs second-hand bicycles. The eBoxes were introduced to respond to gaps in the bicycle sales and repairs market, and focus on building local skills amongst community members to ensure a long lasting impact.

This ‘Complete Simplified Manual’ has been developed to provide guidance to all those associated with managing and operating the eBox. It provides information on the roles and responsibilities of those associated with the eBox including the Board of Directors and eBox staff. An abridged version of this manual is also available, which focuses on essential tasks for eBox staff members.

Click below to download the full manuals.

MAMaZ Against Malaria at Scale: Midline Survey Report

The MAM@Scale project is a scale up of the pilot project which was carried out in Serenje district between July 2017 and July 2018. The main objective of conducting the midline review was to gauge progress to date of the MAM@Scale activities. The results in this report reflect progress part way through implementation of the project (the current phase of the project ends on 30 November 2020). The review was carried out in selected project areas to review progress in achievements and assess the possible change that can be attributed to the project, particularly with regards to management of cases of severe malaria. The review was conducted in June and July 2020.

Click below to read the full report.

Results of a community-driven intervention in rural Zambia to reduce child mortality – Evidence Brief

As the global development agenda converges around the Sustainable Development Goals (SDGs) and aims for Universal Health Coverage (UHC), there is much emphasis on the need for an inclusive development approach. To achieve this, communities need to be at the centre of interventions and must have the knowledge and resources to drive their own development agenda according to their local needs. However, in rural Zambia, as in many other sub-Saharan African contexts, communities continue to face multiple barriers in accessing basic services. Underlying factors include geographical, financial and social constraints.

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Importance of gender empowerment to reducing malaria mortality in Zambia – Evidence Brief

Gender equality and women’s empowerment are key to achieving universal health coverage. They are also important in their own right as a means to achieve sustainable development. Building on a successful gender mainstreaming approach used in three earlier projects, MAM@Scale integrated a focus on gender into the design of a severe malaria intervention in Zambia. Community health volunteers (CHVs) were trained to administer quality assured 100 mg rectal artesunate to children with severe malaria danger signs at community level and to refer patients to the health facility for further treatment. The project’s gender strategy aimed to address the wide range of social norms and gender stereotypes that prevented rural households from responding promptly to severe malaria and other child health emergencies.

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Adapting a severe malaria intervention in Zambia in the context of COVID-19 – Evidence Brief

In early March 2020, coronavirus (COVID-19) was declared a pandemic by the World Health Organization. Many countries had started to take steps to isolate suspected cases, ban mass gatherings and public events, close schools and universities and impose social distancing. At the time, MAMaZ Against Malaria at Scale (MAM@Scale) was implementing a community level intervention to address severe malaria targeted to young children in five districts of Zambia, working in partnership with district health teams. Responding to an urgent request by the Ministry of Health (MOH) for development partners to help build community preparedness and resilience, the project swiftly pivoted its activities to integrate a COVID-19 focus.

This evidence brief looks at how MAM@Scale adapted a severe malaria intervention in Zambia in the context of COVID-19.

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Scaling up rectal artesunate in Zambia – Evidence Brief

Over 7,500 malaria deaths occurred in Zambia in 2018 and children under six are the most susceptible due to their lack of immunity. MAM@Scale empowered Zambian families in five districts (Chitambo, Serenje, Chama, Manyinga and Vubwi) to reduce their mortality risk from severe malaria by introducing artesunate rectal capsules (known locally as rectal artesunate or ‘RAS’), a cutting-edge pre-referral intervention given at community level to children aged six months to six years old. The MAMaZ Against Malaria (MAM) pilot project (2017-2018) reported a reduction in severe malaria case fatality from 8% to 0.25% in intervention sites in Serenje district.

Building on this evidence base, MAM@Scale began implementation in December 2018 with funding from Grand Challenges Canada, Medicines for Malaria Venture and Transaid. Originally an 18-month intervention, additional funding from FIA Foundation, Grand Challenges Canada and a private donor extended the project by six months and enabled the inclusion of a COVID-19 focus. MAM and MAM@Scale built on a longer-term investment in community health systems strengthening by two earlier projects.

This evidence brief looks at scaling up progress so far and highlights some key lessons to guide wider national scale up of the innovation.

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Case study: Chitambo District Health Office (DHO) partnering with MAM@Scale in the COVID-19 response

The collaboration between Chitambo District Health Office (DHO) and MAM@Scale has been very effective, not only in the treatment of severe malaria at community level using rectal artesunate, a pre-referral drug, but also developing strong preventative measures against COVID-19 in this transit town.

MAM@Scale uses a strong community engagement approach by establishing and strengthening community systems to uplift health standards at community level. It is an inclusive approach that engages people at all levels, from traditional leadership to members of the community. People who volunteer to work for the community are trained in health education and become the providers of basic health services at community level. Food banks and savings schemes are formed in the communities to fight affordability barriers. This has not only raised demand for health services in the facilities that MAM@Scale is supporting in Chitambo district, but it made it much easier to put up preventative measures against COVID-19.

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Case Study: Baron educates people on malaria, emergency transport systems and COVID-19 on air

Fwanta is a community in the Kabamba area of Serenje District, Zambia.  In the past, many people in Fwanta who developed medical complications, be it maternal or malarial related, died because people wrongly interpreted the danger signs.

A turning point happened when MAMaZ Against Malaria at Scale (MAM@Scale) began working with this community and the Kabamba Rural Health Centre. They trained Community Health Volunteers (CHVs) on the management of severe malaria at community level through the administering of a Rectal Artesunate Suppository (RAS). MAM@Scale also provided an emergency transport system (ETS), in the form of a bicycle ambulance, to Fwanta.  Baron Mupeta was one of the people selected to be trained as an ETS rider.

Click below to read Baron’s testimonial.

Case Study: Brenda Kundo

Community Health Volunteers (CHVs) are the backbone of the health system in rural Zambia, where they provide invaluable health advice to their communities, which are located prohibitively far from health facilities. Before the pandemic, CHVs were a vital part of our MAM at Scale programme, combatting malaria in their community by educating families on the danger signs of severe malaria and administering RAS (rectal artesunate suppositories), a pre-treatment for children with suspected severe malaria.

CHVs are a trusted voice in their communities, so it was natural that they would form the cornerstone of MAM at Scale’s COVID-19 response. To meet the challenges of the pandemic, the MAM at Scale team has orientated nine Community Facilitators on COVID-19, who have in turn trained 1,379 CHVs, who will help keep their communities safe during the pandemic.

Brenda Kunda is a Community Facilitator with MAM at Scale. A tragic experience in Brenda’s life eventually led to a positive change, not only for her, but for her family and her entire community.

Click below to read Brenda’s story.