Family planning in Madagascar: lessons from a conservation NGO

Blue Ventures has increased contraception use from 10% in 2007 to 55% today. What can the global health community learn?

The national contraception use rate in Madagascar is 29%. Yet in Velondriake, a remote area in the southwest of the country, it is 55%. Just 10% of the community were using contraceptives in 2007 when the marine conservation organisation Blue Ventures launched Safidy, its family planning programme. So how did it do it?

Safidy, which means "choice" in Malagasy, was born out of a desire to help the communities Blue Ventures was working with. The area had virtually no health infrastructure and a focus group revealed a huge need for family planning. Agathe Lawson, the United Nations Population Fund representative in Madagascar, who supports Blue Ventures and a number of other family planning initiatives in the country, says that asking the community for what it wanted was instrumental to Safidy's success. "Sometimes we can pre-empt what people want but qualitative research is essential."

What is less obvious is why a conservation organisation would take on the work of a health NGO. "We took it on because no one else would, and because it would benefit our work," says Dr Vik Mohan, Blue Ventures' medical director and the brain behind Safidy.

The case for population, health and environment initiatives isn't new: population growth puts pressure on natural resources. Mohan says that around 20% of the world's population lives in biodiversity hotspots. Population growth in these hotspots is 40% higher than in other areas because they are often remote and with few health or education services. Yet there are plenty of conservation organisations working in biodiversity hotspots whose resources or networks could be used to provide additional services to local communities.

Lawson says that programmes that combine environment or livelihood issues with population services create what she calls "a chain of connectivity" whereby people are much more aware of the balance between humans and their environment.

Blue Ventures initially sought to partner with Marie Stopes to provide family planning services in Velondriake but the area was too remote for it to provide its usual services. So instead it decided to train community-based distributors (CBDs), local women who would be able to counsel and prescribe contraceptives. It was a cost-effective method, which promoted local capacity and built on the community-based approach Blue Ventures was championing in its conservation work.

Jennifer Pope, the deputy director of the Sexual Health and Tuberculosis Department at PSI, says that with a general shortage of healthcare workers in developing countries, the CBD model is an attractive option because it fills a gap whilst allowing the few medical professionals to focus on more complicated issues.

CBDs in Velondriake received training from PSI and Mohan, a practicing GP in the UK. All CBDs can prescribe the pill and sell condoms but only the more senior CBDs can do contraceptive injections (which last three months). Longer-acting methods such as implants and coils are provided by Marie Stopes four times a year at a mobile clinic. Pope says that this chain of referral is essential to uphold women's free and informed choice and ensure they have access to the contraceptive method that best suits their circumstances. She adds that the pricing structure must also be set so that cost doesn't influence the patient's choice.

Velondriake now has 32 CBDs who cover about 40 villages. CBDs buy contraceptives at cost from PSI (Blue Ventures pays for the transport) and sell them at a small profit. The service is highly valued by the community and since 2007, the fertility rate has dropped by 40%.

"We chose to do everything in-house but there is no reason it has to be that way," says Mohan. "You could partner with a health provider but if you can integrate effectively, you can get great synergies between these different activities."

Blue Ventures initially thought Safidy would be integrated into the health system (the health ministry has been involved since the start) but with the political crisis that followed the 2009 coup, it is unlikely to happen in the near future. Some 400 primary health care centres have closed in Madagascar since 2009, according to Lawson.

Pope says that there are many ways CBD initiatives can cut costs down by piggybacking on the private sector for their supply chain or working with other organisations – be they private, public or non-profit – to lower overheads and build sustainability.

Safidy currently receives financial support from the MacArthur Foundation and logistical as well as medical supervision from Blue Ventures. Mohan is working on future-proofing Safidy, lowering its costs and testing how far Blue Ventures can pull back. The most important component is refresher training and supervision for the CBDs to maintain a high quality of care, but Mohan thinks it could be done for £10,000 a year.

For the time being, Blue Ventures is expanding Safidy to Belo-sur-Mer, another area in southwest Madagascar and as a result of its experience in Velondriake, the programme was up and running in just four months.

"We do not have the contraception prevalence rate that Blue Ventures has anywhere else in Madagascar," says Lawson. "It means that their strategy works and we must continue to give them support."

• The article was amended on 13 November 2013 to state that 10% refers to usage of, and not access to, of contraceptives in 2007. The fertility rate has also dropped by 40% since then.

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Emilie Filou

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