Rehana Ahmed, MD- Top Réseau, Population Services International, Madagascar
After completing training as a medical doctor in Pakistan and the UK, Dr. Ahmed managed an IPPF-funded clinic in Pakistan and converted the clinic into a Center of Excellence. In 1995, she joined Social Marketing, Pakistan an affiliate of Population Services International (PSI) and led the development of clinical services, including intrauterine devices (IUDs). During ten years of cooperative work between Greenstar Social Marketing and PSI she initiated and managed provider training, then became the CEO and member of the Board of Directors. She worked to develop policies, strategies and the funding base, which led to Greenstar becoming Pakistan's largest private provider of contraceptives.
In 2004 Dr. Ahmed relocated to Kenya and became a freelance health consultant in maternal and child health and family planning (FP). Currently she is a freelance Reproductive Health (RH) specialist and Social Franchise Advisor.
The HIV/SRH Integration site interviewed Dr. Ahmed about PSI provision of integrated services in Madagascar.
Can you provide background information on the HIV/AIDS and sexual and reproductive health situation in Madagascar?
- HIV/AIDS: In Madagascar, the prevalence rate of HIV is 0.977% among the general population and 1.13% among pregnant women. Madagascar is among the few countries in Sub-Saharan Africa with an opportunity to slow the HIV epidemic and avert the socio-economic destruction experienced in southern/eastern Africa. While 8 in 10 women and 9 in 10 men have heard of HIV/AIDS, only half of women could cite the condom as one method of HIV prevention. Some 50% of women and 25% of men have not heard of sexually transmitted infections (STIs), and blood samples showed a national average of 4% syphilis infection1 and 8% among pregnant women2.
- STI: STI treatment is important because people infected with STIs are more likely to become infected when having sex with an HIV-infected partner. Youth are an important focus for STI prevention efforts in Madagascar given that nearly half of the population is under 15 and most new STI and HIV infections occur among young people. Certain risk groups in Madagascar have extremely high rates of STIs. The 2003 DHS showed that 9% of truckers, 12% of military, and 18% of commercial sex workers (CSWs) had symptoms of an STI in the preceding 12 months. Research in Antananarivo and Tamatave reveals that 39% of women in general, 62% of occasional sex traders, and 64% of CSWs presenting at health clinics with genital discharge syndrome have at least one active STI3. Among this sample, 25% of the CSWs had syphilis and 35% had cervical infection caused by either gonorrhea or chlamydia. A study conducted through the Institut Pasteur in a rural community in Diego province in 2002 found STI rates three to four times higher among the 15-24 age groups than among 25-49 for gonorrhea and chlamydia4 .
- RH: Malagasy youth report early onset of sexual activity, yet low levels of knowledge on STI/HIV/AIDS. Research indicates that youth seldom consult medical services for sexual and reproductive health (SRH) issues, preferring the informal pharmaceutical sector instead. Barriers include lack of confidentiality and poor understanding of youth SRH needs.
- FP: Over the past six years, Madagascar has made important strides in family planning. Contraception among women in union progressed from 19.4% (1997) to 27% (2003) 5 the contraceptive prevalence rate (CPR) for modern methods increasing from 9.7% (1997) to 18.3% (2003) . There remains a tremendous unmet need in Madagascar for improved family planning. Some 41% of all women surveyed in 2003 indicated that they want no more children and 29% that they desire birth spacing for 2-4 years6. However, contraceptive prevalence is low: 10% for injectable contraceptives (ICs), 3% for oral contraceptives (OCs), and 1% for condoms7.
Knowledge regarding reproductive health and the facts about family planning methods is also low. Although some 84% of women 15-49 know of a modern family planning method, almost one-third have no intention of using these because they unnecessarily fear secondary effects or other health problems8. The PSI/M 2004 TRaC distribution survey shows that 43% felt that pills or injectables could render them sterile.
Please tell me about a project /program experience integrating HIV/AIDS and sexual and reproductive health services.
With a start up grant from the Bill and Melinda Gates Foundation, PSI/Madagascar launched the Top Réseau (TR) franchised network of private clinics in 2000 to improve access to quality, affordable sexual and reproductive health services among vulnerable groups, in particular youth. TR providers are private practitioners with their own clinics. Once they agree to become TR members, they receive training on youth-friendly integrated service delivery, STI treatment and family planning counseling and product use. They also agree to adhere to PSI-defined quality norms and standards, and receive monthly support and supervision visits. PSI uses routine monitoring, clinic audits and mystery clients to monitor the quality of services.
Selected TR providers are also oriented on sex worker-friendly service delivery.
At present, 146 Top Réseau clinics and 204 doctors exist in seven large cities of Madagascar. In 2004, requests for HIV test represented 10% of young clients' reasons to visit Top Réseau's health centers for reproductive health services. Hence, to better respond to their needs, Voluntary Counseling and Testing (VCT) for HIV was integrated in 14 Top Réseau clinics in June 2006 in four cities under the brand extension Top Réseau +. VCT services were extended to another city in February 2007, for a total of 16 centers in five sites.
How did you decide on the approach to take?
Surveillance data indicate high syphilis rates and low HIV prevalence in Madagascar, suggesting that program interventions focusing on STI prevention among high-risk groups will be most effective in controlling a possible HIV epidemic. In addition to that, a detailed assessment of youth and RH needs was conducted during the first year of the project and the results stated that youth have preference for integrated services rather than stand alone clinics for fear of stigmatization. Thus, PSI/M utilized lessons from other relevant social marketing programs including PSI's voluntary counseling and testing program in Zimbabwe, promotion of youth-friendly reproductive health services during the SMASH (Social Marketing for Adolescent Sexual Health) project in Botswana, and PSI/Mozambique's successful STI prevention kit project to implement the social franchise of youth friendly RH services.
Generic and branded communications materials are developed and disseminated using a mixture of mass and interpersonal techniques (such as radio, TV, mobile video units and peer educators).
What were the dates of the project/program?
- August 2000: letter of approval for TR Social Franchise received from the General Secretary of the Ministry of Health and FP
- December 2000: launch of the pilot project in Toamasina (main coastal port city)
- December 2002: PSI Madagascar won the R2 GF for HIV (includes large funding for Top Reseau), grant ended following 3 month no cost extension in fall 2006
- Oct 2003: first extension to Antananarivo (capital)
- 2005 further extension to 3 additional sites
- 2005: obtained USAID 3 year grant (Aug 05-Aug 08) for RH/HIV and MCH includes funding for Top Reseau
- October 2005: letter of approval for VCT HIV services integration received from the Ministry of Health and FP of Madagascar
- June 2006: integrated VCT services launch in 4 sites, clinics that offer VCT are branded Top Reseau +
- September 2006: extension of TR network to another 2 sites with USAID funding
- February 2007: VCT services integrated in two other clinics, for a total of 16 clinics in 5 cities
What was the problem you were responding to when you developed the program?
Madagascar is one of the last remaining countries in Sub-Saharan Africa with a HIV prevalence less than 1%. Surveillance data indicate, however, that prevalence is increasing, due to the very high STI rates and widely practiced high risk behaviors, as mentioned above. Nearly half the population in Madagascar is under 15 and most new STI/HIV infections occur among young people. Youth are among those at highest risk of HIV/STIs and are a priority for prevention programs. Given that the HIV epidemic is a concentrated epidemic, targeting is essential to ensure that preventive activities reach the groups most at risk, namely youth, sex workers, men who have sex with men (MSM) and direct clients of sex workers.
In addition to HIV/STIs, the program also works to provide FP counseling and products to youth (pills, condoms). Use of FP products among young women is low, with rates of unwanted pregnancy and unsafe abortion increasing.
Who was involved in the discussion and decision-making on the approach to take to address the problem?
- Youth 15 to 24 years old
- Stakeholders/Local leaders/ authorities
- PSI Washington
- Ministry of Health & FP
- Ministry of Sport and Youth
- Ministry of Education
- ONM/CROM (National Order of Doctors and their regional bodies)
Did you involve the community in developing the program?
A one-week workshop was held to discuss the program, its objectives, its approach and what PSI expects from local partners, with local authorities and parents.
How did you work with the District Health Office in setting up the program; for example, in strengthening the systems and services?
Each health facility (private or public) in the community is under the supervision of the District Health Office (DHO) of the respective region. The program has the responsibility to report to the Médecin Inspecteur of the DHO. The Coordinator (a PSI-hired medical doctor) of each site of the TR program must give them monthly, quarterly and annually reports on all activities following the GOM's Management Information System (MIS) system. The TR program has improved public-private sector collaboration, giving the DHO the opportunity to work closely with representatives from the private health sector, which did not exist before the launch of the program.
The RH or STI/HIV staff member responsible from the DHO is invited to be one of the trainers of the TR franchise members, which further increases goodwill and collaboration and, at the same time, ensures that the norms and standards promoted for the franchise members in, for example, STI syndromic management, family planning, and VCT conform with national policies.
Are there links to community support groups?
The program collaborates closely with local PLWHA associations in the five sites where TR+ services exist. In case of an HIV-positive client, TR+ providers refer them to the public sector for care and support services.
Peer educators (PE) in each TR site have a "Fan's Club" that help them to identify where youth are gathering/hanging out, to schedule their outreach activities, and to mobilize youth to attend these sessions.
How do the providers and clients feel about the integrated activity?
Providers' feelings: The integrated activity enlarges their range of services, for which they receive periodic training offering opportunities for continuing education in reproductive health. This encourages providers to remain on the cutting edge of their profession; PSI also organizes regular meetings for doctors in each TR site, to allow for sharing of experiences and professional networking.
Integrated services further increases their client flow; that is, their "business". We also find that it encourages client loyalty, and facilitates follow-up visit/control. Integrated services provide the opportunity to offer multiple services in just one visit and ensure that there are no missed opportunities when young men and women present themselves to health care providers.
Clients' feelings: They feel there is no discrimination/stigmatization about their real reason for visiting the clinics, and it is more practical for them because they can have the opportunity to have a package of RH services, that is, "all the RH services they should need in just one setting" (counseling, treatment, follow up visit). In addition, they feel that their confidentiality is respected.
What obstacles did you encounter from a program standpoint and how did you address them?
The obstacles included limited access to mass media (i.e., radio, TV, newspapers) by the project target groups; and high number of youth living in rural areas that are not attending school (80% of 15-24 year olds), which limits the ability to reach large number of youth through interpersonal communication. We use MVU (mobile video unit) activities to reach youth living in peri-urban areas.
Promotion of the TR franchise through mass media is considered unfair competition by other private medical providers, and is forbidden by the Deontological Code (franchophone code is really different from the Anglophone one, which is more "practical and favorable to promoting public health"). To overcome possible local resistance among public and private providers, PSI systematically organizes regional representation visits to the CROM (regional body of the national order of doctors); invites the president of the ONM (national order of doctors) to train TR providers on the Deontological code; organizes an "Adolescent RH Day" and invites all private and public medical providers in each implementation site to inform them about the program, its objectives and what it can contribute to the health of their localities.
In terms of geographical extension, we are limited to selected urban sites with a critical mass of private providers. Though there are more than 1500 private doctors in Madagascar, they are concentrated in a relatively small number of cities. Given the considerable resources PSI invests in building up the TR network in each site, it is not cost effective to work with less than 8-10 clinics per site.
Improving and maintaining quality of services in clinics that are not under our direct 'control' remains a challenge.
With the geographical extension of the network it becomes more difficult to adhere to a standardized service delivery and promotion/communication approach. The Senior coordinator regularly visits the team and reminds them/works with them to ensure that standards are as uniform as possible throughout the network.
At present, PSI does not directly sell pharmaceutical products to medical providers but has to go through pharmaceutical distributors and wholesalers. To some extent this limits the reach of our FP and STI treatment products. While private doctors are allowed to 'stock' and sell socially marketed products, it remains difficult to ensure use of (e.g., PSI prepackaged treatment kits for ulcers and urethritis). Most doctors prescribe and refer the client to a pharmacy or medical store for the product, making it more difficult to influence correct treatment/product choice and use. We have a team of medical detailers that promote correct product use - they visit private providers including members of TR, and pharmacies throughout the country.
Did you make adjustments to your approach as you went along?
We have improved the monitoring and evaluation methods, and now use TRAC studies every 2 years as they provide actionable and timely results that help adjust the approach/ communication strategy of the program. We continue to refine our quality monitoring system, including the minimum standards and the quality indicators for the main services provided with PSI support. We invest considerably in the program's staff ability to collect data, manage the information and use it to define/adjust their activities.
We have also modified our incentives system for peer educators: they have monthly objectives for number of outreach sessions (individual, group and large groups either at PSI office or at a TR clinics), and are paid based on achieving these objectives.
At present, there are 7 teams of youth peer educators (one team of up to 12 girls and 12 boys per site), 7 teams of SW peer educators (3 per site), 3 teams of high risk men peer educators (3 per site), and 2 teams of MSM peer educators (2 per site). PSI is increasingly working with all these groups to encourage behavior change, early treatment seeking for STI symptoms and VCT.
Did you have need for special resources to implement your approach (e.g., funding, staffing, supplies, consultants)?
For the MIS of the franchise, we requested support from a consultant to assist with improving the existing data base. This is ongoing work that now is done in part by a PSI/M local MIS coordinator
For PEs: we use field supervisors to keep them motivated to assure the quality of their activities, and for reporting on the number of youth, SWs, etc. reached.
We have a full time local consultant on staff who ensures the quality of IPC work and ensures that training activities of peer educators are participatory, adult learning focused, etc. We also have the luxury of an in-house RH/HIV communication department that develops the mass media work for TR including radio and video, and the promotional items for outreach teams and doctors.
At present, we have no funding for VCT activities, which we pay for using our own program income obtained from product sales. We also run our MSM activities on a pilot basis/shoe string in anticipation of additional funding in 2008.
How did the project team decide on a system to balance work activities (e.g., addition of new activities with existing activities for the purpose of integration)?
Each TR site has an Adjunct Program Coordinator whose mission is to represent the program and assure the coordination/supervision of all activities in the field with a special focus on relations with the franchisees. We see opportunities to integrate syphilis testing in selected sites, but need funding to do so. Public sector support for our work is strong, and our local Adjunct Program Coordinator invests a lot of time in public relations and representation exactly for that reason.
The program has a detailed generic services implementation plan that can be adapted when introducing a new service.
Were there systems you developed to manage integrated services, such as client follow-up or special complicated cases?
Data on the various RH services such as SRH counseling (general), FP and STI diagnosis and treatment, is included in one central MIS and reporting system. Following local and PSI/W guidelines, data on VCT services are collected and stored in a separate MIS system. We have no system to track follow up cases or complicated cases at the clinic/provider level.
We developed a social franchise manual to serve as a reference document, indicating to members in detail how to provide high quality integrated RH services for youth.
Was there training needed in order to be able to offer integrated services?
Providers needed constant training, supervision and support to serve broader RH needs. As such, we trained them specifically to offer integrated services because it is not in their habit to suggest systematically different services for each visit of the client. They had to learn how to promote the concept of an integrated service in a "smooth" way and for the benefit of the client. Their initial training is an integrated training and addresses adolescent RH counseling, FP and STI treatment. Given the length and special nature of the training and the doctors' limited availability to attend a long training, VCT training is held separately.
How did you evaluate the success of your activity?
- TRAC survey: comparing baseline and follow-on survey every two years of the program
- Mystery Client survey: to monitor the quality of the services
- Trends of clients flow through our MIS system
- Qualitative research
- Informal feedback from partners/donors, etc
Do you have reports or tools related to the project? Could you tell us the URLs or provide electronic files?
- SMRS (Social Marketing Research Series) : PSI reports on TRAC or MAP survey available in www.psi.org
- TR Franchise Manual
- Mystery client methodology
-
IEC/CCC tools: STI brochure, Condom brochure, modern FP method tools, STI and FP flipcharts, prevention kits, my changing body tools, TR promotional TV spots, TR sites directory leaflets
- Training curricula: for franchisee, for PE
For more information on PS's work in Madagascar, see:
http://www.psi.org/where_we_work/madagascar.html
Contact Information
Rehana Ahmed
Director, PSI Board
Cell(254)734-660957
rehana@psikenya.org , rehanas2@yahoo.com
www.psi.org
Letje Reerink
ietjer@psi.mg
Voahirana Rajoela
voahiranar@psi.mg