Attachment_J-5_TA_Background_Strategy.pdf

ATTACHMENT J.5 – TECHNICAL AREA BACKGROUND STRATEGY

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Technical Area Background

1. FAMILY PLANNING AND REPRODUCTIVE HEALTH

According to the CIA World Factbook estimate, Madagascar’s population will reach 22,585,517 by mid- 2012; and, is expected to reach 42.3 million by 2050; the island nation has the ninth highest population growth rate (2.95 percent) in Sub-Saharan Africa. Furthermore, the population is young, with 43 percent under 15 years of age (PRB, 2011)1. The modern Contraceptive Prevalence Rate (CPR) dramatically increased from 5.1 percent in 1991 to 29.1 percent in 2008/09 (DHS). Results from a national survey undertaken by PSI from December 2010 to March 2011 recorded that CPR remained at 29 percent in the face of population growth and a deteriorating health system. Some sub-Saharan African countries are now demonstrating two percent to six percent increases in CPR per year. Madagascar’s national goal is to increase the MCPR to 34 percent by 2015.

Nearly two-thirds of Malagasies are under twenty-four years old (2010); the average age is a youthful 18.2 Most adolescent reproductive health indicators have stagnated or deteriorated between 1992 and 2008. In 2008/9, more than a quarter of adolescent girls aged 15-19 years old had at least one child, and five percent did so at 15 years of age or younger. The proportion of teenagers who began childbearing actually increased from 29 percent in 1992 to 31.7 percent in 2008/9. Finally, in 2008/9, 44 percent of teens (15-19 years old) spaced their births only 7-23 months apart as opposed to 50 percent in 2003/04 (DHS 2008/9). Not surprisingly, female adolescents (15-19 years of age) constitute the highest unmet need group: 26.9 percent desire to either space or limit pregnancy, but are not accessing a modern family planning method.

There are still urban (36 percent) and rural (28 percent) discrepancies in modern contraceptive prevalence (CPR) rates with wide regional variations (DHS 2008/9). CPR also varies significantly across wealth quintiles. Only 17.6 percent of the poorest Malagasies use modern methods compared with 36.4 percent the richest (DHS 2008/9). In addition, unmet need for family planning, at 19 percent, remains a serious constraint and the current contraceptive mix relies heavily on short-term methods such as injectable contraceptives (18 percent of all sexually active women) and oral contraceptives (6 percent). Finally, Sexually Transmitted Infection (STI) rates are extremely high in Madagascar, especially in certain most-at-risk groups.

To date, Madagascar’s family planning efforts have depended heavily on financing from donors (UNFPA, USAID, and World Bank), which altogether accounted for 99 percent of spending for contraceptives from 2004 – 2008 (World Bank, 2010). In 2006, the Malagasy government allocated funds to purchase contraceptives for the first time, although with the current political crisis that funding has ceased. USAID and UNFPA continue to procure the large majority of Madagascar’s contraceptives, with USAID’s contribution channeled through the private sector using social marketing since 2009.

USAID/Madagascar’s current strategy for family planning is to continue focusing on expanding access to quality services for rural and underserved communities, increase investments in Behavior Change Communication (BCC), improve access to quality private sector service provision, strengthen focus on

1 Population Reference Bureau 2011 World Population Data Sheet 2 http://www.indexmundi.com/madagascar/median_age.html youth and post-partum women, and expand the contraceptive method mix, especially by expanding access to long-acting and permanent methods (LAPMs).

2. MATERNAL, NEWBORN, AND CHILD HEALTH (MNCH)

Madagascar has seen dramatic improvements in infant and under-five mortality. Under-five mortality decreased dramatically from 92 per 1,000 live births to 72 per 1,000 and infant mortality decreased from 59 per 1,000 to 48 per 1,000 (DHS 2003/4, 2008/9). Large geographic (urban/rural) and income differences exist in child health outcomes. A multivariate analysis of three successive DHS surveys indicate that child survival is impacted by education of the mother, access to better sanitation and clean water, and multiple births (World Bank, 2010). Relatively low coverage of immunization (62 percent complete coverage children 12-23 months), exclusive breastfeeding (51 percent children less than six months), high stunting (50 percent of children under five) and anemia rates (50 percent children under five) indicate that there are still important child health issues needing to be addressed in Madagascar. The prevalence of diarrhea is low and decreasing (18 percent in 2003/4 and 8 percent in 2008/9), mostly among children aged 6-23 months, but with wide geographic variations. In addition, 14 percent of all children under five years of age admitted to a hospital in 2009 were diagnosed with severe malaria (INSTAT, 2010)3, which is a leading cause of under-five mortality and, according to UNICEF, kills approximately 20,000 Malagasy children every year.

Early and exclusive breastfeeding is the highest impact, preventative child survival intervention with the potential to avert 13 percent of all child deaths.4 Malagasy children are universally breastfeed (98 percent); however, the proportion of children put to the breast within 24 hours of birth decreased from

88.4 percent in 2003/4 to 63.3 percent in 2008/9 (DHS). The likelihood for the mother to breastfeed her child immediately following the birth is correlated with the assisting health provider (clinician or traditional midwife), her level of education and the household’s socioeconomic status. Still, more than one fifth of Malagasy newborns receive other foods to eat before being put to the breast following delivery; this proportion increases to nearly 1/3 in rural areas and among the poorest households. Early initiation of breastfeeding protects newborns from infection and reduces the risk of newborn mortality5.

Providing the first milk, or colostrum, not only provides essential nutrients and immune protection to the child, but it can stimulate production of breastmilk and breastfeeding in itself can facilitate emotional bonding between mother and child6. As a result, Madagascar has a low coverage of exclusive breastfeeding (51 percent of children less than six months), and the trend has stagnated over the past ten years (48 percent in 1997). Furthermore, the median duration for exclusive breastfeeding (in months) decreased from 3.6 in 2003/4 to 2.4 in 2008/9; the median duration among the lowest wealth quintile is just one month (DHS).

Vitamin A deficiency decreases a child’s immunity and can increase child mortality by 23 percent.7 Nearly 80 percent of Malagasy children ages six months to three years consumed vitamin A-rich foods in the 24 hours prior to the last DHS survey; however, less than half of the same children (45.7 percent)

3 Institut National de la Statistique de Madagascar. http://www.instat.mg 4 Lancet Nutrition Series, 2003.

5 Edmond, KM et al. Delayed breastfeeding initiation increases the risk of neonatal mortality. Pediatrics, 2006, 117(3): e380‐

386).

6 Klaus, M. Mother and infant: Early Emotional Ties. Paediatrics, 1998, 102: 1244‐1246.

7 Levinson, James F. and Bassett, Lucy, p.3.

consumed iron-rich foods in the same time period. Vitamin A-rich food sources are available and consumed throughout the country; yet, 43 percent of rural households consumed iron-rich foods in contrast to 69 percent of urban households (DHS). Micronutrient deficiencies also significantly affect economic productivity; the World Bank estimates that Madagascar loses more than $720 million each year in GDP as a result.

Anemia, an underlying cause of chronic ill health, is quite high in the Malagasy population, although the prevalence has been decreasing in recent years. Anemia places children at risk for infection, delays in cognitive development and limited physical capacity, and for pregnant women affected, fetal development is compromised and risk of maternal death is higher during childbirth.8 Efforts to address anemia through mass biannual campaigns on national level for deworming of pregnant women and children under five coupled with an increased focus on malaria through the President’s Malaria Initiative (PMI) have undoubtedly contributed to dramatic anemia decreases anemia in the last five years. In 2003, 70 percent of children under five were anemic, and currently, about half of children ages six months to five years are anemic with no difference between girls and boys; the majority (49.6 percent) suffer from mild or moderate anemia whereas severe anemia affects one percent. Iron deficiency is estimated to contribute to about half of all cases of anemia9 and with low iron intake through the diet, additional efforts need to be placed on improving diet diversity and quality in conjunction with deworming and malaria prevention and control programs. Nearly 4 in 10 pregnant Malagasy women (38 percent) suffer from mild anemia;

unfortunately, anemia is associated with one-fith of maternal deaths due to pregnancy complications.10

3. MALARIA

Malaria is endemic in 90 percent of Madagascar, however, the entire population is considered to be at risk for the disease. Reported malaria cases and deaths through the national Health Management Information System have shown decreasing trends in morbidity and mortality between 2003 and 2009. Overall, hospital deaths attributed to malaria decreased from 17 percent in 2003 to six percent in 2009 (PNLP, April 2010). In 2009, malaria was responsible for an estimated four percent of all reported outpatient visits and 14 percent of all children under- five years of age admitted to a hospital were diagnosed with severe malaria (SSS, 2010). In spite of this, malaria remained the leading reported cause of overall hospital mortality and hospital under-five mortality in 2009.

Decreases in malaria morbidity over this time period are likely attributable to the national scale up of prevention interventions largely supported by the Global Fund, the USG’s President’s Malaria Initiative and other donors. As a result, major progress has been made achieving high Long Lasting Insecticide treated Nets (LLINs) usage among all individuals and vulnerable groups. LLIN use by children under five years increased from 58 percent in 2008-9 to 89 percent in 2011 and for pregnant women increased from 57 percent to 85 percent in the 91 LLIN targeted health districts (2008/9 DHS, 2011 Malaria Indicator Survey11). Among LLIN targeted districts, ownership increased from 72 percent for one or more LLINs in a household in 2008/2009 to 94 percent for ownership of at least one LLIN per household in 2011. In addition, indoor residual spraying (IRS) has been expanded to 53 districts covering an estimated 79 percent of households in targeted zones (MIS 2011).

11 Malaria Indicator Survey 2011, http://www.measuredhs.com/publications/publication‐pr12‐preliminary‐reports.cfm

Through the President’s Malaria Initiative, USAID supports free mass distribution of LLINs every three years, year-round distribution of socially-marketed LLINs, IRS, provision of Rapid Diagnostic Tests (RDTs) at the community level, and behavior change communication activities for malaria prevention and treatment. With the exception of LLIN social marketing, USAID plans to continue support to all these activities.