A 2014 World Bank figure estimated that 90% of Madagascar’s population lived on less than 2 USD a day. In 2013, the total health expenditure was around 4.2% of the GDP. The cost of medical care is high relative to the average Malagasy income, making access to health care difficult, more so for the 640’000 disabled people (WHO estimate) needing specialized treatment. There are few trained medical professionals, including in the field of physical rehabilitation. Physical rehabilitation centres lack funding to purchase raw materials/components and equipment, limiting services. Madagascar ratified the Convention on the Rights of Persons with Disabilities in 2015.
To help make treatment more accessible to persons with disabilities, we encourage health authorities, the medical community, NGOs and other partners to work together to define common objectives, draft a strategy and action plan, and allocate more resources to strengthen and ensure the sustainability of the national physical rehabilitation sector. The results of an assessment of physical rehabilitation have been presented to this partnership platform to guide their planning. We will work primarily with the Ministry of Health (MoH) who is spearheading this process, under a cooperation agreement lasting until 2019.
While the national physical rehabilitation sector is still unable to provide free, good-quality services, persons with disabilities can access care through a referral system and through our support in covering the costs of their treatment and the transportation/accommodation expenses during their therapy/consultations. Three physical rehabilitation centres provide and improve their services with our direct assistance, in the form of material and component supply, management coaching, and professional development opportunities for staff/technicians (for example, training courses adapted to local needs/capacities and scholarships abroad). The centres receive expert advice, for instance on establishing quality-control and beneficiaries satisfaction mechanisms and identifying technical and clinical gaps that may be addressed by training activities. We specifically encourage these centres and other partners to look beyond the provision of orthopaedic shoes and work towards meeting the more prevalent need among disabled patients, which is for orthoses/prostheses; technical guidance on device production will thus be provided/increased.
RESOURCES USED (As at September 2016)
- CHF 385’501 Budget 2016
- CHF 221’987 Expenditure
- 146 working days of PT and P&O expert
MAIN ACTIVITIES AND ACHIEVEMENTS (Jul-Sep 2016)
- The SFD team has given support to the CAM and the CRMM to update their stock follow-up and prepare their annual order of material. The SFD validated the annual order for CAM (72’264 CHF) and CRMM (29’553 CHF), the delivery is planned in Q4 2016. With this order, the SFD helps both physical rehabilitation services providers to dispose of the appropriate and cost effective raw materials and other components.
- The SFD focal person has done his first follow up visit to CAM to assess the financial situation and talk about implementing the cost calculation for devices. Understanding costs of devices is a first step toward financial sustainability for the center. It also contributes to preparing discussions with MoH on the inclusion of physical rehabilitation services in Universal Health Coverage.
- The two Essential Management Package (EMP) team finalized the evaluation tool EMSAT at CRMM and CAM, including prioritisation matrix result, and shared the results amongst the teams from both centers. Although the implementation of the EMP took more time than expected, the EMP team (with initial training by LMG in Bangkok) is now taking the lead in a very appropriate way.. By providing the EMSAT management capacity assessment tool, the SFD helps CRMM and CAM to get a clearer managerial picture of the centers.
- The SFD provided technical and financial support to the MoH to organise a short consultancy with FATO president Mr Masse in Madagascar. He gave his input on the national strategic plan to support the development of the physical rehabilitation sector.
- The Gait training facility for amputee and wheelchair has been completed at CRMM. This allows better synergies amonst the clinical team (P&O and PT).
- Collaboration regarding the review of the national plan is ongoing (both CBM and SFD are the main stakeholder mobilising the MoH for this file
- The SFD encourages national authorities to appropriately recognize the profession of Prosthetist / Orthotist and Physical Therapist. The documents were submitted to the MoH regarding Physiotherapy in order to start with the recognition process.
INDICATORS (As at September 2016)
Physical Rehabilitation National Entity
- Existence of National plan: Under development
- % of health Budget allocated to physical rehabilitation: n/a
- Number of professionals employed by the entity: 1
Qualified professionals employed by our partners’ rehabilitation centers
- 1 P&O
- 17 Physiotherapists
- 26 other therapists
Quality of services delivered by our partners
- Technical assessment: n/a
- Beneficiary satisfaction survey: n/a
Beneficiaries’ statistics – Trainings (jan-sep 2016)
- 2 persons received a professional P&O training
- 12 persons received a clinical training
Beneficiaries’ statistics – Services (jan-sep 2016)
- 3’580 physical rehabilitation services provided by our partners
CHALLENGES AND NEXT STEPS
- CAM has finally hired a stock keeper that will hopefully stay in place after numerous turnover on this position. The stock management needs a lot of reorganisation and a proper computerised system needs to be put in place in order to allow for a more efficient and cost effective management raw material and components.
- The physical rehabilitation is still not seen at the ministry level as a priority. The review of the national plan for physical rehabilitation, as well as the implementation of the inclusion plan, still need to be supported by the international stakeholders.
- The frequent turnover of management staff at the ministry complicates our activities. For example our interlocutor at the Ministry of Population with whom we had started discussing the implementation of the plan for inclusion, left his position from one day to the other.
- The implementation of PP technology has a consequence on the cost of the devices that are dramatically under estimated and cannot be ignored. Once the cost calculation is done for both CRMM and CAM a plan has to be put in place with the centres to work both on the quality and accessibility in order to develop sustainability.
- The SFD met with Miracle feet during the FATO congress; they confirmed their will to implement a project in Madagascar focusing at the treatment of children with clubfeet in collaboration with the MoH. They are looking for a local partner to develop the project, and the SFD will continue the discussion to evaluate the feasibility of its participation.