The Challenges of Health Care in Remote Madagascar

By Hailey Reeves, IGHS master’s student

Over the past two months, I have had the opportunity to visit 10 remote villages in the Androrangavola commune in the Ifanadiana district of Madagascar. I worked with the Drones Observed Therapy System (DrOTS) project, which aims to address the lack of access to tuberculosis (TB) care and information in remote areas of Madagascar.

This project has several components:

  • Using drones to transport TB lab samples from remote areas to a centralized laboratory where the specimens can be analyzed for TB diagnosis
  • Implementing a video training curriculum to assist patients in understanding and managing their TB diagnosis, as well as to aid village health workers in streamlining their work
  • Using medication adherence technologies (e.g. electronic monitoring boxes) to remotely monitor patient treatment adherence
UCSF Institute for Global Health Sciences student Hailey Reeves working in a tent with two male nurses from Madagascar
Hailey Reeves, right, meets with nurses in Madagascar.

As a subset of this larger project, my capstone research focused on evaluating the video training curriculum. I traveled with the DrOTS medical team to educate communities about TB and evaluate knowledge acquisition from the videos. This has been an extremely rewarding experience, and one that I will treasure for the rest of my life.

Although each of the villages I visited is unique in its own way, they all face similar problems when it comes to health: an extreme lack of health workforce and healthcare infrastructure. For the entire Androrangavola commune (which is home to approximately 2,700 people), there are two official community health workers. In each village, there is meant to be one person who corresponds with the community health workers, but these individuals are usually farmers and are not trained in health care. Further, there is frequently only one of these “correspondents” for every two or three villages, which almost always are separated by great distances. This extreme lack of health workforce, in addition to little health care infrastructure, means people suffer from a wide variety of diseases that go untreated.

As a part of the traveling medical team for the DrOTS project, I found myself concerned about the lack of care for people in these remote communities. Our team provides care for TB only. While the medical team will provide advice to those without TB, they cannot directly assist them. The doctor will tell them to go to the nearest medical center (a 2 to 12-hour hike, depending on the village) in order to get care.

This ethical dilemma became even more pointed when we were hiking to villages for follow-up visits with previously diagnosed TB patients. Because there are no roads, we would hike several hours to reach a single patient to give them the treatment they needed. After treating the patient, we would leave the village and leave behind the countless individuals who needed care for other diagnoses.

A common illness I encountered during my time in this region was schistosomiasis, a disease caused by a water-borne parasite. Even though I didn’t see many cases myself, people often talked about how common the disease was and said that they wanted to know more about it.

Before going to Madagascar, I had been taught that a disease like schistosomiasis is highly preventable. While schistosomiasis can be prevented, the reality of prevention in remote areas of Madagascar is a whole different story. Avoiding infested waters is nearly impossible when you are a rice farmer who spends every day standing in rice paddies. Moreover, in remote villages, people’s source of water for drinking and washing is the nearest stream.

It can be very easy to sit in a classroom thousands of miles away and list all of the ways one can prevent and treat an illness, but the reality is much different on the ground. It was a very humbling experience to understand the difficulties the Malagasy people face in avoiding preventable disease such as schistosomiasis.

Despite facing many challenges, such as lack of health workforce and a high prevalence of preventable diseases, the Malagasy people in the Androrangavola commune persist. They work hard to provide for their families and foster a strong sense of community in their villages. My capstone research experience showed me that these people are eager to learn more about how they can improve their health and the health of their communities.