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A Study on the Department

Management of Lutheran Health in
Madagascar

号:

博 士 生:

LBYZ20100006
Raonimahafaly Eugene

学科专业: Management Sciences and Engineering.
指导教师: Prof .Yang Shuwang
Associate Prof .Yi Ming
所在学院: School of Economics and Management

二○一五年五月

学校代码:10491

研究生学号:LBYZ20100006

中国地质大学
博士学位论文
A Study on the Department Management of Lutheran
Health in Madagascar
博 士 生:

Raonimahafaly Eugene

学科专业:

Management Sciences and Engineering

指导教师:

Prof. Yang Shuwang
Associate Prof. Yi Ming

二○一五年五月

A Dissertation Submitted to China University of Geosciences for the
Doctor Degree of Management Sciences and Engineering

A Study on the Department Management of
Lutheran Health in Madagascar
Ph.D Candidate:Raonimahafaly Eugene

Major:

Management Sciences and Engineering

Supervisor:

Prof. Yang Shuwang
Associate Prof. Yi Ming

China University of Geosciences
Wuhan 430074 P. R. China

中国地质大学(武汉)研究生学位论文原创性声明
本人郑重声明:本人所呈交的博士学位论文( A Study on The Department
Management of Lutheran Health in Madagascar),
是本人在导师的指导下,在中国地质大学(武汉)攻读博士学位期间独立
进行研究工作所取得的成果。论文中除已注明部分外不包含他人已发表或撰写
过的研究成果,对论文的完成提供过帮助的有关人员已在文中说明并致以谢意
本人所呈交的博士学位论文没有违反学术道德和学术规范,没有侵权行为
,并愿意承担由此而产生的法律责任和法律后果。

学位论文作者签名: Raonimahafaly Eugene

期: 2015

年 5 月 11 日

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本人授权中国地质大学(武汉)可采用影印、缩印、数字化或其它复制手
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涉密论文解密后适用于本授权书。

学位论文作者签名: Raonimahafaly Eugene

期:

2015年 5 月 11日

作者简介
My name is Raonimahafaly Eugene and I am from Madagascar. I am studying PhD of
Management Sciences Engineering in University of Geosciences in China, under the kindness of
CONABEX (National Commission of Foreign Studies). Today, I have completed 37 credits hours
to complete the credits requirement.
I readily finish the three Publications and they were published at the journal site IISTE for
October 2104. They are three newspapers under the title and the references:
“The Operational Management of Rosewood in Madagascar”. Research on Humanities and
Social Sciences www.iiste.org. SSN (Paper) 2224-5766 ISSN (Online) 2225-0484 (Online) Vol. 4,
No, 24, 2014.
“Process Management Project Ambatovy Madagascar”, Research on Humanities and Social
Sciences www.iiste.org, ISSN (Paper) 2224-5766 ISSN (Online) 2225-0484 (Online) Vol.4, No.24,
2014.
“Project Management for Department of Health Lutheran Church in Madagascar”. Journal of
Biology, Agriculture and Health care www.iiste.org. ISSN 2224-3208 (Paper) ISSN 2225-093X
(Online) Vol.4, No.24, 2014.
Hence my project, namely to achieve improve the management strategies of health in
Madagascar. In addition, my project represents a qualifier objective and long term. It’s renewable
at each occasion by the partnership that was proposed at the management school.
I am interested in the field of exploration of health management techniques in our government.
Consequently, it was decided to train and develop statements shall standard specificity of
management in all the ministers. The aim of this study is to develop and apply new management
approaches to identify additional opportunities for health management department activities.
My experience in this research as based for Management Sciences Engineering was an
essential part of my education. Following this experience, I learned some important features of
system management. It requires clarity of approach, which is of significant importance in research.
Finally, discussions started during the research are important because they allow ample researcher
opportunity to assess the progress of research by learning how management research approaches a
certain problem.

A Study on the Department Management of Lutheran Health in
Madagascar
博 士 生:
指导教师:

Raonimahafaly Eugene
Prof. Yang Shuwang
Associate Prof. Yi Ming

摘要
信义健康马达加斯加部门管理是创造和维持健康的人很重要的条件。这项研究是基于对母亲和新生儿的
产妇服务于本部门管理的管理和运行状况分析.为了,这项研究提供了降低孕产妇和新生儿死亡率在马达
加斯加和帮助各国实现其目标的千年发展。重要的是要提高医疗保健中心的卫生质量,预防和治疗常见
的并发症,在母亲和新生儿是很重要的。马达加斯加满足其2100万居民孕产妇和新生儿的健康需求之前
主要挑战.产妇死亡率是根据最新的人口与健康调查估计为每百英里498人死亡活产。妊娠有关的原因她
的一生中,一个女人马达加斯加死亡的风险是在45.这些确凿的统计数据显示,需要改进对产科和新生儿
紧急情况。马达加斯加政府已采取了提高产科和新生儿紧急情况,包括具体的国家政策批准的重要步骤
,将药物基本药物的国家名单,并授权助产士执行救生程序.尽管这些措施造成的进步,还是有显著的差
距。这项研究是基于对医疗质量的健康计划开展了母亲和儿童在马达加斯加。多国研究的目的是纲领性
规划用于改善孕产妇和新生儿保健服务的质量在每个国家和世界各地。客观实践的发展和快速的数据收
集工具和综合指标。这个目标生成基准估计,反反复复,最终估算在不同国家执行调查方案措施的评估
的一部分.全国研究的目的是作为卫生设施的描述横断面调查。它是经卫生马达加斯加卫生部和公共卫生
学院的独立伦理委员会的伦理委员会.这些方法包括现有的服务直接观测,卫生设施的国家,并采访了卫
生保健提供者。七个数据采集器团队已在评估预防和分娩前后常见并发症的管理在36个医疗机构观察到
的关怀,从平均每3天.管理部门为中心记录每天超过两胎.他们主要是公共机构(81%),其中四分之三
是不同级别,区,地区,大学医院和四分之一由基本卫生服务中心两(参见附录中的卫生设施在研究的完
整列表级别)分娩的观察(N=347)和产前咨询(N=323)是评估的一个特征.除了收集观测数据,球队已
经取得了四种类型(一般情况下,产前,产房和药房)和面试,包括知识测试场所报表,与百39提供商
。多数受访提供商和观察助产士。从不同类型的收集和分析数据一起的,护理质量评价可能产生母性关
怀在马达加斯加最经常光顾的卫生设施的纸描述。这个评估的结果显示,即使有些地方表现尤为出色,
仍然有差距医护的所有阶段,对孕妇和新生儿,构成孕产妇健康利益相关方采取行动的机会。详细合同
审查本报告中并覆盖产前护理,预防感染,劳动和交付无并发症,子痫或先兆子痫工作,新生儿延长产后
出血和复苏。对一般问题的观察和讨论,也提出.这项研究的结果表明,有上改善响应查明的差距,应根
据,在特别是在卫生设施状况是愿意提供的服务的基础,医疗保健提供者和往常惯例的了解相关的质量
劳动和分娩产科和新生儿紧急情况时的产前保健和护理.一些在使用各种方法确定各技术领域中最显着的
间隙介绍如下.关于卫生设施状况是愿意提供服务,供应商和工作场所缺乏大多数服务产前护理,劳动和
分娩产科和新生儿护理和急救的协议。同样,指导方针和目视助航尚未得到广泛应用,并显示。即使在
基本药物或工作人员可用,奇怪的是他们不使用的物资缺乏或额外的设备。有与这些产品相关用品药品
和服务的可用性之间的差距。例如,谈到调查的卫生设施,77%有铁或叶酸,但是该产品只适用于第一
次观察到的产前咨询的一半.还存在提供与实际观察到的日常护理的报告或服务内提供的服务之间的间隙
。例如,据报道,在计划生育咨询是在卫生设施71%持续提供。然而,已经观察到在仅20%的产前协商
。所有的组件本身,甚至当他们被制成,观察期间未进行优化一定的程序和措施。例如,在完成药品的2

8%,少数已经开始在正确的时间,几乎没有被填在推荐的时间间隔。如果在大多数产前协商进行血压测
量,已经进行了正确地在不到一半的情况下。服务提供商的知识特别低的条件并发症,是产妇死亡的马
达加斯加,包括先兆子痫或子痫的主要原因.平均得分上评估知识,如何做人和干预措施,以重出血的病
例可应用于因产后子宫无子宫收缩仅达39%,并涉及到评估得分认罪,如何做人和干预万一胎盘滞留或
产品设计的要施加只是36%。如果平均分数评价先兆子痫或子痫的或诊断率为70%,小于第三提供商知
道,如果使用硫酸镁和抗高血压稳定;做什么对女人使癫痫发作时,平均得分仅达50%。供应商有相对更
好的了解产妇医疗保健新生儿的护理。总体来说,供应商有一个更容易或更用来提供有关医疗干预信息
提供咨询的健康行为,寻求保健和医疗服务的直接环境之外的患者。因此,有错失机会提供基本服务或
引用这些服务在产前护理和劳动和分娩。这项研究的发现导致了一些政策和方案建议,以加强对孕产妇
和儿童保健在马达加斯加卫生设施的质量。在国家一级,所有机构的关键利益攸关方和各学科应共同商
讨并制定策略应对这一报告的调查结果。一些具体建议如下。国家政策文件已经制定,以促进高品质的
孕产妇和新生儿保健服务。它们包括国家生殖健康政策,国家政策医院的路线图降低产妇和新生儿死亡
率在2005和2015年附录和文档标准。虽然这些文件提供给卫生工作者,有必要通过培训,监督和提供设
备,材料和药品医疗设施,以支持其传播.作为一个重要的建议,我们应该制定一个实施计划,以支持并
实施的卫生设施和卫生工作人员的政策文件已准备好提供孕产妇和新生儿的健康服务质量每一个女人怀
孕了,每一个新生儿。国家政策文件已经制定,以促进高品质的孕产妇和新生儿保健服务。它们包括国
家生殖健康政策,国家政策医院的路线图降低产妇和新生儿死亡率为2005和2015和文档标准或标准附件2
所列。虽然这些文件提供给卫生工作者,有必要通过培训,监督和提供设备,材料和药品医疗设施,以
支持其传播。作为一个重要的建议,我们应该制定一个实施计划,以支持并实施的卫生设施和卫生工作
人员的政策文件已准备好提供孕产妇和新生儿的健康服务质量每一个女人怀孕了,每一个新生儿。评价
结果表明,如管理和监督工作的简单的技术使用药,防止产后由孩子出生的第三期主动管理和使用硫酸
镁先兆子痫或子痫的预防和治疗并不总是一部分卫生保健提供者的现行做法。第二个重要的建议是,我
们应该建立一个机制,分配给医疗服务提供者更新系统的技术和生产信息表。这些技术更新,应根据最
新的证据,提供常规孕产妇和新生儿的健康干预措施。该建议书已经解释了培训手册,协议和直观教具
进行必要的程序和服务的产前保健,预防感染,劳动和分娩产科和新生儿护理和急救的保健设施.该建议
已确保了基本设施,如自来水和电的供应是所有卫生设施标准.
该建议已确保所有卫生设施提供的用品,设备和基本药物需要提供基本干预产前护理,预防感染,劳动
和分娩产科和新生儿护理和急救和提供对使用新装备的训练。该建议已加强监测系统,以促进遵守的服
务和常规护理紧急运送国家政策和临床指南。建议在产前护理,预防感染,劳动和分娩的先兆子痫或子
痫,领域取得阻碍了新生的工作或长期复苏。他们中的一些简要讨论。关于产前护理,例如,供应商应
在手或张贴服务指南,包括筛选和性传播感染的管理,人的免疫病毒咨询和检测,预防传播由母亲传染
给人类免疫缺陷病毒的儿童。预防感染可以通过确保供应商有保护设备与客户接触的每一个,并鼓励他
们在处理每次使用后0.5%的氯溶液,可提高。各地劳动和分娩服务,可以通过培训和持续支持对人际交
往,包括程序的劳动和分娩期间的解释,患者的诱因提出问题,并就特定主题,如计划生育产后得到改
善。先兆子痫或子痫,有必要提供指导方针和数据表进行咨询蛋白尿对先兆子痫或子痫和产前检测。在
阻挠或产程延长的情况下,有必要提供指导,提供培训和监督并倡导定期和系统地使用药作为工作管理
工具来诞生的时间(开始时间和合适的频率)。同样,建议为产后提供指导,以确保为用户提供第三个
阶段分娩的主动管理关于新生儿复苏的三个组成部分中,确保新生儿的系统监测和护理最优的卫生条件
。建议通过优先医疗机构提供临床编队,其中有一个比较高的孕产妇和新生儿死亡率和/或在内陆地方引
用难以扩展这些行动的实施。
关键词:部门;管理;卫生.

A Study on the Department Management of
Lutheran Health in Madagascar
Ph.D Candidate: Raonimahafaly Eugene
Supervisor : Prof.Yang Shuwang
Associate Prof.Yi Ming

ABSTRACT
The Department Management of Lutheran Health in Madagascar is important for creating and maintaining
conditions for people healthy. This research is based for management and health analysis of mother and newborn
at the maternity service in this department management. In order, this research gives to reduce maternal and
neonatal mortality in Madagascar and helping countries to achieve their targets for the Millennium Development.
It is important to improve the quality of health care in health center sanitation to prevent and treat common
complications in the mother and the newborn. Madagascar has major challenges before meeting the maternal and
newborn health needs of its twenty one million inhabitants. The maternal mortality was estimated at four hundred
and ninety eight deaths per one hundred miles live births according to the latest Demographic and Health Survey.
The risk that a Malagasy woman dies of pregnancy related cause during her lifetime is one in forty five. These
damning statistics show the need to improve access to obstetric and neonatal emergencies. The Malagasy
Government has taken important steps to improve obstetric and neonatal emergencies, including approval of
specific national policies, adding drugs to the national list of essential medicines and authorizing midwives to
perform life-saving procedures. Despite advances resulting from these measures, there are still significant gaps.
This Study is based on Quality of Care conducted by the Health Program on Mother and Child in Madagascar.
The objectives of the multi-country study are programmatic planning for improving the quality of maternal
and neonatal care services in each country and worldwide. The objective develops practical and fast data
collection tools and composite indicators. This objective Generates baseline estimates, and repeatedly, final
estimates in the various countries where the survey is part of an evaluation of program interventions. The study of
nationwide was designed as descriptive cross-sectional survey of health facilities. It was approved by the ethics
committee of the Ministry of Health in Madagascar and the Independent Ethics Committee of the Faculty of
Public Health. The methods included direct observations of existing services, states of health facilities and
interviews with health care providers. Seven data collector teams has evaluated the care observed in the
prevention and management of common complications around birth in 36 health facilities, from an average of
three days each. The department of management was center recording more than two births per day. They were
mainly public institutions (81%), three quarters of which were hospitals of different levels (district, regional,
university) and a quarter consisted of basic health centers level two (see Appendix for a complete list of health
facilities in the study). The observation of deliveries (N = 347) and prenatal consultation (N = 323) was a feature
of the assessment. In addition to collecting observational data, the teams have made statements of places of four
types (general, prenatal, maternity ward and pharmacy) and interviews, including knowledge tests, with hundred
thirty nine providers. The majority of interviewed providers and was observed midwives.
From the different types of data collected and analyzed together, evaluation of the quality of care could
generate an ad-hoc description of maternal care in the most frequented health facilities in Madagascar. The
findings of this assessment show that even if there are areas where performance is particularly good, there remain
gaps in all stages of care for pregnant women and newborns, constituting opportunities for maternal health

stakeholders to act. Detailed contracts are examined in this report and cover the prenatal care, infection
prevention, the labor and delivery without complications; Eclampsia or Preeclampsia work with extended
postpartum hemorrhage and resuscitation of the newborn. Observations and discussions on general issues are also
presented. The recommendations focus on policies, the provision availability of health facilities and specific
services components. The findings of the study show that there is a basis on which improvements in response to
identified gaps should be based, in particularly in the status of health facilities to be willing to offer the services,
knowledge of health care providers and usual practices related to quality of prenatal care and care during labor
and birth and obstetric and neonatal emergencies. Some of the most notable gaps in various technical areas
identified using various methods are presented below.
Regarding the status of health facilities to be willing to offer the services, providers and workplaces lack the
protocols for most services Prenatal Care, Labor and Childbirth Obstetric and Neonatal Care and Emergency.
Similarly, guidelines and visual aids were not widely available and displayed. Even where essential drugs or staff
was available, it happened that they are not used by lack of supplies or additional equipment. There are gaps
between the availability of supplies medicines and services related to these products. For example, talking about
the health facilities surveyed, 77% had iron or folic acid, but this product was only available in the first half of the
observed prenatal consultations. There is also a gap between services provided within the reports or services that
are available and actually observed daily care. For example, it was reported that counseling on family planning
was provided consistently in 71% of health facilities. However, it has been observed that in only 20% of prenatal
consultations. Of all the components itself, even when they were made, certain procedures and interventions were
not performed optimally during observations. For example, among the 28% of completed partograms, few have
been started at the right time and virtually none have been filled at the recommended intervals. If the blood
pressure measurement was performed in the majority of prenatal consultations, it has been carried out correctly in
less than half the cases.
The knowledge of service providers were particularly low in terms complications which are the major causes
of maternal deaths in Madagascar, including the Pre-Eclampsia or Eclampsia. The mean score for knowledge on
assessment, how to behave and the interventions to be applied in cases of heavy bleeding due to postpartum
uterine non-contracted uterus only amounted to 39% and the score plea relating to the assessment, how to behave
and the interventions to be applied in case of retained placenta or product design was just 36%.If the average
score for evaluation or diagnosis of Pre-Eclampsia or Eclampsia was 70%, less than a third of providers knew
stabilize if using magnesium sulfate and anti-hypertensive; about what to do against a woman making seizures,
the average score only amounted to 50%. Providers had better knowledge of maternal health care in relation to
the care of the newborn. Overall, providers had an easier or were more used to deliver information about medical
interventions for patients that provide counseling on health behaviors, seeking care and medical services outside
the immediate context. Therefore, there are missed opportunities to deliver essential services or reference to these
services at the Prenatal Care and Labor and Childbirth.
The findings of the study have led to a number of recommendations for policies and programs to enhance the
quality of maternal and child health care in health facilities in Madagascar. At national level, the key stakeholders
of all institutions and all disciplines should work together to discuss and develop strategies in response to the
findings of this report. Some specific recommendations are presented below. National policy documents have
been developed to facilitate maternal and neonatal health services of high quality. They include the National
Reproductive Health Policy, the National Hospital Policy, the Road Map for the Reduction of Maternal and
Neonatal Mortality for 2005-2015 and document standards in Appendix. Although these documents are made
available to health workers, it is necessary to support their dissemination through training, supervision and the
provision of equipment, materials and medicines to health facilities. As a key recommendation, we should
develop an implementation plan to support and operationalize the policy documents for health facilities and
health workers are well prepared to provide maternal and newborn health service quality every woman pregnant
and every newborn.
National policy documents have been developed to facilitate maternal and neonatal health services of high
quality. They include the National Reproductive Health Policy, the National Hospital Policy, the Road Map for

the Reduction of Maternal and Neonatal Mortality for 2005-2015 and document standards or standards listed in
Appendix 2. Although these documents are made available to health workers, it is necessary to support their
dissemination through training, supervision and the provision of equipment, materials and medicines to health
facilities. As a key recommendation, we should develop an implementation plan to support and operationalize the
policy documents for health facilities and health workers are well prepared to provide maternal and newborn
health service quality every woman pregnant and every newborn. The evaluation showed that simple techniques
such as the management and supervision of the work using the partograph, preventing Postpartum by Active
Management of the Third Period of child birth and the use of magnesium sulfate for the prevention and treatment
of Pre-Eclampsia or Eclampsia are not always part of the current practices of health care providers. A second key
recommendation is that we should develop a mechanism for updates systematic technical and production
information sheets for distribution to health care providers. These technical updates should be based on the latest
evidence for the routine provision of maternal and newborn health interventions.
The Recommendation have explained the training manuals, protocols and visual aids for essential procedures
and services prenatal care, infection prevention, Labor and Childbirth Obstetric and Neonatal Care and
Emergency in health facilities. The recommendation has ensured the availability of basic facilities such as
running water and electricity is a standard in all health facilities. The recommendation has insured that all health
facilities are provided with the supplies, equipment and basic medicines needed to deliver essential interventions
Prenatal care, infection prevention, Labor and Childbirth Obstetric and Neonatal Care and Emergency and
provision of training on the use of new equipment. The recommendation has Strengthened monitoring systems to
promote compliance with national policies and clinical guidelines in the delivery of service and usual care
emergencies.
Recommendations were made in the areas of Prenatal Care, prevention of infections, Labor and Childbirth,
the Pre-Eclampsia or Eclampsia, obstructed the work or prolonged resuscitation of the newborn. Some of them
are briefly discussed here. Regarding the Prenatal Care, for example, providers should have in hand or posted
guidelines for services, including screening and management of sexually transmitted infections, human immune
virus counseling and testing and prevention of transmission from mother to child of Human Immune deficiency
Virus. Infection Prevention could be improved by ensuring that providers have the protective equipment for each
contact with clients and encouraging their treatment at 0.5% chlorine solution after each use. Services around
Labor and Childbirth could be improved through training and ongoing support on interpersonal communication,
including the explanation of procedures during labor and childbirth, the incentive of patients to ask questions and
on specific topics such as the Family Planning postpartum. For Pre-Eclampsia or Eclampsia. It is essential to
provide guidelines and data sheets for counseling on Pre-Eclampsia or Eclampsia and detection of proteinuria
prenatally. In cases of obstructed or prolonged labor, it is essential to provide guidance, to provide training and
supervision and to advocate for the regular and systematic use of partograms as work management tool to time of
birth (start on time and with appropriate frequency). Similarly, it is recommended to provide guidance for post
partum, to ensure the provision of all three components of the Active Management of the Third Period Childbirth
Regarding resuscitation of newborn , ensure systematic monitoring and care of the newborn in optimal hygienic
conditions. It is recommended to extend the implementation of these actions by prioritizing the health facilities
that provide clinical formations, which have a relatively high maternal and neonatal mortality and / or are in
landlocked places where reference is difficult.

Keyword: Department, Management, Health.

目 录
Chapter 1 Introduction .............................................................................................................................. 16
§1.1 Research Background........................................................................................................................ 16
§1.2 Purpose and Objectives of the Study................................................................................................. 17
§1.3 Study Questions ................................................................................................................................ 18
Chapter 2 literature Reviews ..................................................................................................................... 19
§2.1 Strategies for Integrating Primary Health Services in Middle- and Low-Income Countries ........... 19
§2.2 Programmers with Other Health Services for Preventing HIV Infection and Improving HIV
19
§2.3 Impact of Prevention of Mother to Child Transmission Programmers on Maternal Health Care..... 19
§2.4 Strategies for Integrating Second Health Services in Low- and Middle-Income Countries ............ 20
§2.5 Integration of Maternal, Neonatal and Child Health and Nutrition, Family Planning: ..................... 20
§2.6 Review for Mother and Child Management by the Ministry of Health ............................................ 21
§ 2.7 the health situation economic ........................................................................................................... 21
2.7.1 Markets code of the mother and child Public Health………………………………………………...19
2.7.2 The Computer Integrated System of Management of Public Finances health. ........................... 22
§2.8 Overall Objective of the Mother Child Health Management Assessment ........................................ 23
Chapter 3 Methodology............................................................................................................................. 24
§ 3.1 Design of the Study and Tools for Data Collection ......................................................................... 24
3.1.1 Quality of Care Survey Tools ..................................................................................................... 24
3.1.2 Grid Observation of Prenatal Care .............................................................................................. 24
3.1.3 Grid Observation of Labor and Childbirth .................................................................................. 24
3.1.4 State Health Facilities Locations................................................................................................. 24
3.1.5 Interview with Health Care Providers ......................................................................................... 25
§3.2 Samples Provided .............................................................................................................................. 25
3.2 .1 Health Facilities ......................................................................................................................... 25
3.2.2 Health Agents.............................................................................................................................. 25
3.2.3 Consultation of Labor and childbirth and Prenatal Care ............................................................. 25
§3.3 Data Collection.................................................................................................................................. 26
3.3.1 Management and Data Analysis ................................................................................................. 26
3.3.2 Approval on Ethics Plan ............................................................................................................. 26
Chapter 4 Results ...................................................................................................................................... 27
§4.1 Actual Samples.................................................................................................................................. 27
4.1.1 Characteristics of Service Providers Interviewed ....................................................................... 28
4.1.2 Sample characteristics for the Antenatal Care Observation ........................................................ 29
4.1.3 Sample Characteristics for Labor and Childbirth Observation ................................................... 29
§4.2 Availability of Drugs and Essential Supplies .................................................................................... 29
4.2.1 General Evaluation of the locations and Health Centers’ Infrastructure .................................... 29
4.2.2 Availability of items for Ensuring Quality of Childbirth ............................................................ 29
§4.3 Essential supplies for Normal Childbirth and Delivery with Complications .................................... 30
§4.4 Signal Functions of Obstetric and Neonatal Care Emergency Performed Complete Course .......... 32
§4.5 Knowledge and Skills of Health Care Providers ............................................................................... 36
4.5.1 Pre-Eclampsia / Eclampsia Fictitious case.................................................................................. 38
4.5.2 Resuscitation Simulation of a New Born .................................................................................... 38
4.5.3 Prenatal Care Observations ......................................................................................................... 39
§4.6 Observations of Labour and Childbirth............................................................................................. 41

§4.7 Observations of Cases of Complications .......................................................................................... 49
4.7.1 Number of cases and training health ........................................................................................... 49
4.7.2 Availability of medicines ............................................................................................................ 49
4.7.3 Assumptions and warning ........................................................................................................... 50
4.7.4 Number of cases and Centers ...................................................................................................... 51
4.7.5 Assumptions and warning ........................................................................................................... 51
§4.8Availability of Medicines ................................................................................................................... 51
4.8.1 Education and Interventions Additional Postpartum .................................................................. 51
4.8.2 Post Partum Support ................................................................................................................... 52
Chapter 5 Other Cooperation of Department Management Health ........................................................... 54
§5.1 Cooperation between department management and the United Nations Population Fund ............... 54
§5.2 Evaluation an Interim of Program Country ....................................................................................... 55
§5.3 Objectives and Scope of the Evaluation ............................................................................................ 56
5.3.1 Questions and Evaluation Criteria .............................................................................................. 56
5.3.2 Principles and Methodological Approach of the Evaluation ...................................................... 56
5.3.4 Composition of the assessment team .......................................................................................... 58
5.3.5 Expected Documents .................................................................................................................. 58
5.3.6 Responsibility for managing and monitoring the assessment ..................................................... 58
5.3.5 Duration of the contract and conditions of remuneration consultants ........................................ 59
§5.4 Evaluation of activities and materials to maternal health in the health department .......................... 59
§5.5 Development and updating of the texts governing training and midwifery ..................................... 60
§5.7 Activities of Health Management Decentralized ............................................................................ 62
5.7.1 Obstetric Fistula .......................................................................................................................... 62
5.7.2 Family Planning .......................................................................................................................... 62
5.7.3 Challenges in the implementation ............................................................................................... 63
§5.8 Advanced Strategies Result Marie Stops Madagascar ...................................................................... 65
5.8.1 Sensitization ................................................................................................................................ 66
5.8.2 Advocacy .................................................................................................................................... 67
5.8.3 Integration of Reproductive health of adolescents services in voluntary testing centers............ 67
5.8.4 Malagasy Association for Family Welfare ................................................................................. 68
5.8.5 Position of the Reproductive health of adolescents .................................................................... 69
5.8.6 Strengthening national capacity in the production ...................................................................... 70
5.8.7 Advocacy for the integration of Minimum Initial Service in the national contingency ............. 70
5.8.8 Development of Partnerships with No Governmental Organizations ......................................... 71
§ 5.9 Management Materials delivery and United Nations Population Fund ........................................... 71
5.9.1 National Institute of Statistics ..................................................................................................... 72
5.9.2 Other Plan Action of Department Management ......................................................................... 73
Chapter 6 Discussions and recapitulation ................................................................................................. 75
§6.1 Summary of Results .......................................................................................................................... 75
6.1.1 Prenatal Care ............................................................................................................................... 75
6.1.2 Observations of Antenatal Care .................................................................................................. 75
6.1.3 Infection Prevention .................................................................................................................... 76
6.1.4 Knowledge of Providers ............................................................................................................. 76
6.1.5 Observations ............................................................................................................................... 76
6.1.6 Preeclampsia and Eclampsia ....................................................................................................... 77
6.1.7 Observations of Labor and Childbirth in Relation to the Pre-Eclampsia or Eclampsia .............. 77
6.1.8 Obstruction of Labor and Work Extended .................................................................................. 77

§ 6.2 Knowledge Providers ....................................................................................................................... 78
§ 6.3 Findings on All Topics and Discussion............................................................................................ 78
6.3.1 Level Training to be ready to Provide Services .......................................................................... 78
6.3.2 Differences between Levels of Being Ready To Provide Training ............................................ 79
Services and Services Delivered .......................................................................................................... 79
6.3.3 Service Delivery.......................................................................................................................... 79
6.3.4 Knowledge .................................................................................................................................. 79
§ 6.4 limits................................................................................................................................................. 80
§ 6.5 Comparison of Those Findings of Demographic And Health Survey in Madagascar ..................... 81
6.5.1 Prenatal care ................................................................................................................................ 81
6.5.2 Care Childbirth and Breastfeeding .............................................................................................. 81
Chapter 7 Recommendations or Contribution........................................................................................... 83
§ 7.1 Recommendations Regarding National Policy ................................................................................ 83
§ 7.2 Recommendations for All Components and Related to the Level of Health Facilities.................... 84
§ 7.3 Recommendations by Component ................................................................................................... 84
7.3.1 Labor and Childbirth ................................................................................................................... 85
7.3.2 Obstruction of Labour or Work Extended .................................................................................. 85
ACKNOWLEDGEMENT ........................................................................................................................ 86
References ................................................................................................................................................. 87
Annex 1: List of Participating Health Facilities to Stud ........................................................................... 93
Annex 2: Table of frequency District........................................................................................................ 94
Annex 3: Strengthen the Provision of Quality Health Services to the Entire Population ......................... 95
Annex 4: Process Indicators ...................................................................................................................... 97
Annex5: Allocation per Year (US$)........................................................................................................ 104
Annex 6 List of Cost Used ...................................................................................................................... 109

Chapter 1 Introduction
§1.1 Research Background
If one wants to reduce maternal and neonatal mortality in the world and helping countries to achieve their
targets for Millennium Development Goals, it is important to improve the quality of healthcare provided in health
facilities to prevent and treat common complications in the mother and the newborn. Bleeding is the most
common cause of maternal deaths in developing countries: it is responsible for 25% of maternal deaths. In Africa,
the bleeding is the cause of 33.9% of maternal deaths (Khan et al., 2006). Other major causes of maternal death
worldwide are hypertensive diseases in pregnancy (eclampsia which is essentially the source of 12% of deaths),
sepsis (15%) and labor dystocia (8 %). In developing countries, two-thirds of deliveries (62%) take place with the
assistance of a skilled and the least developed countries; it is the case for 31% of deliveries. When she gives birth
in a health facility, women may, if necessary, benefit from the various effective interventions for the prevention,
detection and treatment of obstetric and neonatal complications that are offered there and are taught by qualified
providers.
The quality of maternal and neonatal care in health facilities was evaluated in three large studies conducted
in several countries. First, an investigation within the framework of the Prevention of Hemorrhage Initiative
Postpartum was conducted to assess the performance in terms of active management of the third stage of
childbirth. In the 10 countries where the survey was conducted, the results indicated that efforts to change policies
and programs to promote the Active Management of the Third Period of childbirth and to reduce the Postpartum
have been particularly successful. Second, the Mortality Prevention Program and Disability Nursery in
partnership with the United Nations and the University of North Carolina have developed an evaluation of
obstetric care facilities that was carried out in many countries Third; Macro has developed the survey Assessment
of Benefit Services. These two studies are designed to assess "the level of health facilities to be ready to provide
services" to provide maternal care, including the number and type of health providers found there and the
availability of equipment and medical supplies. The Health Integrated Program Mother and Child, funded by
partenariat, have developed a set of survey tools from health facilities. If the program originally planned to focus
on the diagnosis and treatment of pre-eclampsia and eclampsia, it was later expanded the concept to key practices
for normal labor and delivery and the treatment of major maternal and neonatal complications in childbirth. The
study, which takes its cue from the work of Prevention Project postpartum hemorrhage, fills a gap in surveys of
health facilities by providing for effective evaluation of the Quality of Care through direct observation of services
offered with standard care checklists and knowledge assessment tests providers, both in terms of Antenatal Care
as care related to labor and childbirth.
The department health management has major challenges before it can meet the needs Maternal and
Neonatal Health of its 21 million inhabitants. The average number of births per woman was 4.8 and 40% of
women use some form of contraception. The majority of the population lives in rural areas and 55% of women
give birth without skilled assistance. The infant mortality rate is high at 48 deaths per 1,000 live births. The
maternal mortality ratio is estimated at 498 deaths per 100,000 live births according to the latest Demographic
and Health Survey (2008-2009) and the World Health Organization reported an adjusted rate to 440.10 the
probability that a Malagasy woman dies of pregnancy-related cause during her lifetime is 1 in 45.A recent
assessment of 303 health facilities across the country, funded by the United Nations Population Fund has
highlighted the great need to improve access to obstetric care and Neonatal Emergency in Madagascar. Only 22%
or 7 formations that deal more than 20 deliveries per month fulfilled the training requirements and Neonatal
Obstetric Care Emergency basic or comprehensive. No region of the country had the recommended number of
Obstetric and Neonatal Care formations Emergency ( training with the complete set of facilities providing care

and four basic health care for 500,000 inhabitants) and seven regions n ' had no training Obstetric and Neonatal
Care Emergency. Starting from the expected number of deliveries and complications to be treated, we get an
effective number of complications treated resulting in a "need satisfied" 21%. Early prenatal mortality in health
facilities visited was 121 deaths per 1,000 births. The direct causes were responsible for 84% of maternal deaths
identified in the study by the United Nations Population Fund, the indirect causes of 8% and 8% unknown causes.
As what has been noted worldwide, the most common direct cause was the Hyper Placenta Previa and retained
placenta. Other major direct causes were eclampsia and pre-eclampsia, dystocia of labor and infection.
The Active Management of the Third Period of Childbirth at every birth is a national policy approved in
Madagascar; however, the procedure for an Active Management of the Third Period of Childbirth is not correct in
service delivery guidelines. Oxytocin is on the Essential Medicines List and is generally available in health
facilities. Midwives are authorized to carry the Active Management of the Third Period of Childbirth, including
the administration of oxytocin and controlled cord traction. Although the Active Management of the Third Period
of the Childbirth is integrated into the initial and continuing training, students' skills in this area are not subject to
any evaluation before graduation. The information system for health management provides no indicator for the
Active Management of the Third Period of Childbirth. Magnesium sulfate and diazepam are frontline
anticonvulsant approved the national policy of Madagascar. Magnesium sulfate is on the Essential Medicines List
for Pre-Eclampsia / Eclampsia severe. If hydralazine, nifedipine and methyldopa are first-line antihypertensive
approved for the treatment of Pre-Eclampsia / Eclampsia severe in national politics, but labetolol is not. The
hydralazine and methyldopa listed on the Essential Medicines List for Pre-Eclampsia / Eclampsia and severe
nifedipine was added thereto. Midwives are authorized to carry the diagnosis of Pre-Eclampsia / Eclampsia and
administer the first dose of magnesium sulfate. However, the magnesium sulfate is not always available at the
health facilities. The management principles of Pre-Eclampsia / Eclampsia are incorporated in initial training
curricula and continuous. The information system for health management does not provide support for indicator
of Pre-Eclampsia / Eclampsia severe. The present study in Madagascar complements and expands previous
efforts to evaluate the quality of maternal and neonatal care, and access to them. It is essentially to observe the
care related to Labor and childbirth, the Prenatal Care and interventions for the prevention or management of
common complications that can save lives.

§1.2 Purpose and Objectives of the Study
The purpose of the survey conducted by Quality of Care Integrated Program for Maternal and Child
department health in Madagascar with the support of partenariat was to learn about the quality of key
interventions for diagnosis, prevention and management of complications direct maternal in maternal and
neonatal care in health facilities, to guide quality improvement activities. The study qualifies the word "quality"
as compliance with international guidelines based on internationally recognized evidence. The main objective of
the study Integrated Maternal and Child Health Program is to help reduce maternal and neonatal deaths frequent
and preventable by improving the use and quality of interventions / known beneficial tasks listed in Table 1-1.

Table 1-1. Interventions and Stains Evaluated and Complications Studied in the Care Quality Survey

TESTED INTERVENTION

STUDIED COMPLICATIONS
Routine Prenatal care and prevention and
diagnosis of complications, Including PreEclampsia / Eclampsia and infection

prenatal Care

Systematic obstetric
newborn care

care

and

essential

Normal childbirth and action of prevention and
diagnosis of complications, Including infection

postpartum Hemorrhage
Active Management of the Third Period of
childbirth and management of postpartum
hBlood hpressure and diagnosis by urinalysis, use of Pre-eclampsia / eclampsia
magnesium sulfate in the case of Pre-Eclampsia /
Eclampsia
Correct use of the partograph and implementation of Work prolonged / obstructed,
appropriate measures
neonatal asphyxia and infection
Resuscitation of newborn

neonatal asphyxia

Infection Prevention Practices

Sepsis - neonatal and maternal

stillbirth,

§1.3 Study Questions
The Quality of Care Study was designed to answer the questions of the program:
-Do the policies, standards and guidelines be in line with all the practices of maternal and neonatal care
based on evidence, namely the management of Pre-Eclampsia / Eclampsia and Hyper placenta Previa, the use of
partograph, Active Management of the Third Period of delivery, Prevention of infections and essential care and
neonatal resuscitation?
-Do supplies, medicines, equipment and basic infrastructure for maternal and neonatal care be available?
-Do pregnant women who come to prenatal consultation and women who are in labor and childbirth be the
subject of an examination, diagnosis and, where appropriate, a suitable support of the Pre -Eclampsie /
Eclampsia?
-Did the package of essential interventions in labor and childbirth, namely the management of Pre-Eclampsia
/ Eclampsia, the use of partograph, Active Management of the Third Period of Delivery, Prevention infections
and critical care and neonatal resuscitation be properly implemented?
-What are the obstacles to the improvement of Quality of Care?
Madagascar’s Care Quality study was within the framework of an effort conducted in several countries.
Studies have been conducted including Ethiopia, Kenya, Tanzania and Rwanda in 2010. The objectives of this
multi-country study were to:
-Guide program planning for improving the quality of maternal and neonatal care services in health facilities
in each country and globally. Develop faster data collection tools and practices and composite indicators that can
be used in several countries.
-Generate baseline estimates, and the resumption of the investigation, the final estimates in the various
countries where the survey is part of an evaluation of program interventions.

Chapter 2 literature Reviews
.

§2.1 Strategies for Integrating Primary Health Services in Middleand Low-Income Countries at the Point of Delivery
This systematic review reports on five studies of different forms of integration. The objective of this review
is to assess the effects of strategies to integrate primary health care services on producing a more coherent product
and improving health care delivery and health status. Briggs and Garner examine the impact of adding an extra
component to family planning services and compare both integrated services to specialized services and enhanced
care packages to routine care. They describe four outcomes: health care delivery, service coherence, health care
status for patients, and other outcomes. From these studies, they find that integration has a positive effect on
referrals, while attendance and costs are similar. They find no differences in overall use (which was low), and
knowledge is higher in the vertical (specialized) conditions. Health care delivery shows an advantage for the
integrated provision. Two of the studies show improvement in child factors, with more comprehensive
examination and better child outcomes in the integrated arms. The authors conclude that the results are mixed and
the methodologies may affect intensity and type of provision, concluding that the evidence on integration is
inconclusive. (Briggs and Garner 2006).

§2.2 Programmers with Other Health Services for Preventing HIV
Infection and Improving HIV Outcomes in Developing Countries
This review examines the effects of PMTCT integration on coverage and uptake. The authors were able to
identify only a single study (Megazzini et al. 2010) out of 28,654 potentially relevant references that met their
inclusion criteria. This study reports on a cluster randomized controlled trial in Madagascar with six clinics
providing routine care and six providing integrated models. The findings show a 10 percent increase in
antiretroviral therapy coverage in the integrated models. However, it may not be an ideal intervention because it
fell short of targets as well as universal roll-out of treatment according to guidelines for both mother and baby
(only 52 percent received the maternal and infant treatment). The authors’ caution that basing policy on a single
study is problematic, and that, despite the fact that the gains are statistically significant, the absolute levels of
treatment coverage are far from optimum.(Tudor Car et al. 2011).

§2.3

Impact of Prevention of Mother to Child Transmission
Programmers on Maternal Health Care

This review examines the impact of PMTCT programs on maternal health care and describes three different
levels of verticality of provision: fully vertical, semi-vertical/-integrated and fully integrated (horizontal). The
authors screened 1,627 reports and generated 21 reports. They examined outcomes in terms of antenatal care,
emergency obstetric care, treatment of sexually transmitted infections (STIs), postpartum care, family planning,
skilled birth attendance, and anemia treatment. All of these outcomes cluster around maternal health rather than
child health. A key finding is that 7 of 15 relevant studies report negative effects of Impact of Prevention of
Mother to Child Transmission Programmers on Maternal Health Care programs on antenatal care, including
longer labor, extended waiting time, disruption of services, fear of stigma, and avoidance of antenatal care.
However, 4 of 15 studies describe positive effects, such as improved confidentiality, communication, obstetric
practices, medical supplies, and health promotion, as well as improved emergency obstetric care. Five of six

publications looking at STI treatment find no effects. The two studies that examine postpartum care find no
effect, and seven out of eight that examine family planning describe no effect, with the eighth reporting a positive
effect. The authors conclude that Impact of Prevention of Mother to Child Transmission Programmers on
Maternal Health Care services have both positive and negative effects on maternal health care services,
exacerbated by the semi-integrated nature of provision. Despite the scant evidence, the authors call for more full
integration. (Both and van Roosmalen 2010).

§2.4 Strategies for Integrating Second Health Services in Low- and
Middle-Income Countries at the Point of Deliver
Health care services on health care delivery and health status in resource-poor countries (low and middle
income), based on nine studies. This review differentiates the types of services integrated and shows that
integration of health prevention and control at facility and community levels is a factor in efficacy. Four examine
integration as opposed to single specialized services. The integration strategies services with family planning and
maternal and child health appears to decrease utilization, knowledge, and satisfaction, and has little impact on
health outcomes for mother or child. However, the integration of health prevention has some effect on sexual
transmissible infection treatment and incidence and health incidence. No effect on knowledge or risk is found.
The authors conclude that add-on services have shown the most effective results in the short term. Complex
integration has shown few if any effects on service or health outcomes, and the authors caution against policy
advice in the absence of clear evidence that integration may not necessarily improve health outcomes.

§2.5 Integration of Maternal, Neonatal and Child Health and
Nutrition, Family Planning: Current Evidence and Practice from a
Systematic Cochrane Review
This review analyzes published studies, evaluating the effectiveness of integrating health services with
nutrition or family planning services. Overall, integration of the services is found to be effective; however, the
methodological rigor of the studies is found to be poor, and significant evidence gaps remain. The studies cover
seven forms of service examining four types of integration. The seven services are family planning, antenatal
care, and post-abortion, childbirth, postnatal, child, and nutrition services. The integration issues covered are
health counseling and testing; health prevention, care, and treatment; and psychosocial or other services. The
most common outcome measured is the uptake and use of contraception, which consistently improves in
integrated services. Increases in ART initiation are shown in two studies, and an increase in HIV testing uptake is
shown in four out of five studies. The three studies that examine changes in health outcomes, focusing on
pregnancy and recovery from malnutrition, find positive improvements. Five out of seven studies show an
improvement on the quality of services. One study shows mixed effects, and the only negative outcome is that
workload increased for staff in one clinic when the services were integrated.
Fourteen additional unpublished reports find that integrated services increased the number of human immune
virus exposed children receiving follow-up and care, and found a decrease in the time for ART initiation in
pregnant women, a doubling of the number of women initiated to ART, an increase in use of services among
postpartum women and their infants, improvements in quality of care, and improvements in awareness of human
immune virus risks, human immune virus testing history, and human immune virus testing referrals. Factors that
promote effective integration, within the studies and reports, include staff personality and experience, stakeholder
interest, substantial training and investment, transferable skills, simple and inexpensive integration, integrated
electronic patient notes across services, male partner involvement, client avoidance of inconvenient or highly
crowded ART clinics, and community involvement. Inhibiting factors for effective integration are limited
financial resources, perception of human immune virus positive women that staff are not supportive of their
pregnancies, confidentiality fears of the clients, male partner permission for women to attend services, low level

of human immune virus risk among family planning clients, high staff turnover, staff unwillingness to engage in
discussions about sexuality with clients, extra responsibility seen as additional work, late presentation of care, and
additional waiting times and costs for contraceptives. (Kennedy et al. 2011).

§2.6 Review for Mother and Child Management by the Ministry of
Health
At the instant of Africa, Madagascar is committed to strengthened national research system for mother and
child management, health information and knowledge management in accordance with the ins and outs of the
Ministerial Conference in accordance with the document. Subsequently, as part of implementation of the
statement Madagascar for the development of research for the management of health was adopted at the last
session of the switches in the region Madagascar 31 August in the September 4, 2013. Universal access to the
information technology and communication will reduce the gap between knowledge and action among developed
and developing countries and will be essential to promote the health of mother knowledge management and
individual child: exchange, dissemination and use of research products, the foundation of development of
partenariat the establishment of a critical mass of human resources. Thus the opportunity in the month 5% partner
budget, two criteria becomes real challenges to develop the research system for the management of the mother
and child health that will have impacted positively on public health. There is an effort invested in the
development process to result in the establishment of national research policy for the management of health and
for documentation, consultation and creating political group for work. A rational and equitable management of
funds mobilized will be provided by a national steering committee and coordinating research for health. Thus, the
development of the national research policy for health, with the participation of all concerned by the Research
Department and partners proves essential to ensure the implementation of a synergistic manner. This journal is an
indispensable tool for all those involved in research through which the potential of the research could be
mobilized to improve health and overcome health inequalities in the country. To address the key issues and
challenges for the development of Health Sector, Madagascar proposes that national research policy for the
management of health meeting the needs and priorities of the country, in conformity with international
declarations related thereto and taking into account the objectives for millennia health management development.
(Ministry of Health, Madagascar)

§ 2.7 Health Situation Economic
Madagascar is among the underdeveloped countries in Africa. Although the country has experienced an
average annual growth rate of 6% since the end of the political crisis of 2003, the health problem still affects 68%
of the population according to estimates from the Survey of Households conducted in late 2006. The average
consultation cost per capita of about US $ 290 in 2005. To address this situation, the Malagasy government
launched in late 2006 and implemented from 2007 a new problem Reduction Strategy generation of mother and
child health, very ambitious, providing for the reduction by five years 50% reduction rate and an average
consultation cost per capita of US $ 476. This new strategy called the Madagascar Action Plan relies on a growth
of over 8% annually and will require the mobilization of a health financing estimated at US $ 11.6 billion of
which 9.4 billion USD will come from public finance. More than in the past, the implementation of the
Madagascar Action Plan will seek firstly a better mobilization of public resources and secondly improving the
efficiency of the expenditure framework. The government of Madagascar will therefore continue and strengthen
its reform and modernization of the management of the public health finances. Indeed, despite significant reforms
initiated mainly since 2004, the finances of the Malagasy public health always aware of the weaknesses that
severely restrict performance. Particular among these reforms include the following three most important.

Passed in July 2010 and applied health Finance Act 2011, the Organic Act of the Laws of Health devotes
Finance abandoning the former Budget resources for the benefit of a Budget Programs. This law allows the
improvement of the performance of the health budget due to its focus on results and performance features more
flexible budget with a greater flexibility in the use of bottom.

2.7.1 Markets code of the mother and child Public Health
Together with this important reform, the government has undertaken the modernization of the public
procurement code health. The country has since 2004 and new procurement code health procurement, meeting the
international standard to ensure greater competition and transparency in the procurement of works, goods and
services for government health mother and child. The code, its implementing legislation and institutions relating
thereto have been fully implemented by the end of 2006.

2.7.2 The Computer Integrated System of Management of Public Finances
health.
The establishment of an Integrated Information System for Public Health Public Finance Management
intended to computerize the management, is another important reform. This system currently captures over 90%
of the financial operations of the Ministry of Health in Madagascar. Without having completely changed the
circuitry of public finances including the expenditure. The System Computer Integrated Management of Public
Finances health has improved the execution of expenditure, the availability of better information on the finances
of the central government and improved reporting on the management of public finances health (Law regulation,
Account Management). The impact of these reforms on the overall management of sanitary public finances
remains currently limited because of insufficient time for their implementation. The management of health
Malagasy public finances, despite some positive points, still has a number of gaps. According to the last
assessment in April 2012, Madagascar's health budget is usually credible because apart revenue forecasting,
execution of expenditures is close to forecasts. The Malagasy health budget also has a budget nomenclature
which translated into strategic choices annual budgets. This nomenclature also provides good coverage of the
operations of the central government. Madagascar is also favored by its financial partners for mother and child
health budget supports they grant are predictable and financial information on aid programs and projects are
widely available. The transparency of relations between government agencies is average. On the other hand,
Madagascar can improve the organization and participation in the health budget process. Finally, although we can
still improve the predictability of funds for commitment of expenditures, cash management remains acceptable.
The biggest weakness of the management of Malagasy public finances concerns the internal and external control.
Health control system remains the object of the most important concerns. Despite the existence of two bodies of
internal control (the State General Inspection and Committed Expenditure Control), the control system is failing
particularly in the payment of the balance of control and that of the service made. The quality control
management is neglected because the audit institutions seem more concerned about the irregularities and the
repression of misappropriation. The external health control remains low mainly because of a significant delay in
the presentation of settlement legislation to Parliament and inadequate control by the Court of Audit shall exercise
on public accounting. Since 2010, Priority Action Plan was developed for the medium term and for each year by
the government to pursue the necessary reforms to redress the shortcomings of the health public finance
management system. Its implementation has received significant support from donors Partnership Framework. In
addition, a "Monitoring and Coordination Unit of the Public Finance Reform of health" to design and implement
these reforms was drawn to health mother and child.

§2.8 Overall Objective of the Mother Child Health Management
Assessment
The mother child health management exercise is an integrated monitoring framework for the management of
public finances health. It allows the systematic measurement of the performance of the public financial
management of a country. The methodology has been developed since 2012 by partners in a joint secretariat
comprising the International Monetary Fund, the European Union, the United Kingdom, French, Norway,
Switzerland, and the Strategic Partnership for Madagascar. The information produced by this framework also
contributes to the achievement of government reforms, by determining the effectiveness of reforms and the
identification and capitalization of successful capacity. 2) The mother child health management also facilitates the
harmonization of dialogues between the government and the donor community in a common framework and
corresponding to the International Declaration, which is a framework for performance measurement. It
contributes to the reduction of transaction costs at the level of donors. The mother and child services are a
framework for identifying the strengths and weaknesses of mother and child health financial system in the public
sector of the country. It helps the government and donors to identify priorities in terms of reform, support,
responsibilities; and directs action towards health development goals more extensive. In this sense, it includes a
package of high-level indicators to measure and monitor the performance of health public financial management
systems, these reform processes and those of institutions and a Performance Report that provides framework for
all performance reports for the management of public finances. Especially for Madagascar, the goal is to make a
comprehensive assessment of public financial management of the central government and public health
institutions to assess the performance and quality of the management during the period between 2012 and the end
of 2013.The assessment should enable the Government to have a precise diagnosis of the strengths and
weaknesses of the current system of managing health public finances, with a view of its recovery to achieve the
objectives of the Madagascar Action Plan. The evaluation should also allow to measure the progress made by the
country since 2013 (date of the previous assessment) following the reforms implemented so far. In this sense, it
will highlight the links between the efforts and the evolution of the standard indicators. In order to achieve the
stated objectives above, the assessment will provide specific recommendations attached to redress the
shortcomings. These recommendations should be broken down into operational measures to facilitate their
integration in future Priority Action Plans in the medium and short term. Finally, this study will focus on helping
to build the capacity of government institutions involved in the management of public finances health to conduct
gradually and regularly an independent self-assessment of the quality and performance of public finance
management.

Chapter 3 Methodology
§ 3.1 Design of the Study and Tools for Data Collection
The nationwide study was designed as descriptive cross-sectional survey of health facilities. The methods
used are direct observation of services, the inventory of health facilities and of service providers of verbal
interview. All these methods rely on observation checklists (quantitative) or structured questionnaires. The data
collection tools included observation checklists of Prenatal Care and Childbirth and Labor, the statement of health
center in four areas, an interview guide and an evaluation test of healthcare providers of knowledge. These tools
described below.

3.1.1 Quality of Care Survey Tools
-List of health workers
-State of formations places (GP, Prenatal Care, Labor and Delivery, Pharmacy)
-Review records
-Observation Checklist prenatal care
-Observation Checklist of Labor and Childbirth including maternal and neonatal essential, prevention and
treatment of Hyper Placenta Previa, the Pre-Eclampsia / Eclampsia and resuscitation of newborn
-Interview and assessment of health workers knowledge test
-Interview Guide on National Policy and Pharmaceutical Management
-Field Guide of investigators
-Using mobile phone guide and technical sheet

3.1.2 Grid Observation of Prenatal Care
The observation of clinical practices during Prenatal Care and vaginal deliveries in the formations sample
was done using observation checklists based on international protocols of the World Health Organization for the
evaluation of the Pre-eclampsia and eclampsia during Prenatal Care and support of Pre-eclampsia / eclampsia
(Manual Toolbox for integrated management of pregnancy and childbirth WHO).

3.1.3 Grid Observation of Labor and Childbirth
This grid was based on the protocols of the World Health Organization (manuals Toolbox for integrated
management of pregnancy and childbirth) for evaluation of the Pre-Eclampsia / Eclampsia during labor and
childbirth, the management of Pre-Eclampsia and Eclampsie Hyper Placenta Previa at the Labor and Delivery,
consists and correct use of partographs and correct systematic and essential neonatal care, including neonatal
resuscitation. The general information collected included age, pregnancy and parity of the client; the
qualifications of the service provider and the level of care provided by the clinic (tertiary care hospital, health
center, etc.). The observation checklist was adapted from an instrument used by Stanton et al. in their
investigation of the Active Birth of the Third Period Management under Prevention Project postpartum
hemorrhage, and the document "Best Practices in Maternal and Newborn Care: Learning Resource Packet
material Care Maternal and Neonatal Emergency Essentials and Database "developed by persona health, Access
to Clinical and Community Maternal, Neonatal and Women's Health Services program.

3.1.4 State Health Facilities Locations
Existed tools in places were used to collect data on the conditions of the infrastructure and to check
availability and storage conditions of medicines, supplies and equipment. The inventory was performed once each
provided training and observing supplies, infrastructure and equipment in general and the observation of the area
dedicated to the provision of Prenatal Care Services and Labor and Childbirth and pharmacy.

3.1.5 Interview with Health Care Providers
A sample of health providers involved in Prenatal Care and care of Labor and Childbirth was also
interviewed. Where possible, it was the same providers that had been observed in the services and care prenatal
Care or Labor and Childbirth who were also interviewed. Otherwise, the interview was administered to other
providers of Prenatal Care Services and Labor and childbirth. The first part of this tool is designed to collect
information on the constraints and enablers for the delivery of quality care. The information collected from health
providers were their medical qualifications, training and experience in the provision of services Prenatal care
services, labor and childbirth and neonatal care and information for supervision. The second part of the tool was
composed of a series of multiple choice questions to assess providers' knowledge on identification, care and
treatment of common complications for Maternal and Newborn Health. When knowledge assessment interview,
providers should give all possible answers to questions. In addition, the interviewer probed them to see if they had
no other answers. Each question had between six and 12 correct answers (items). A clinical case study to assess
the clinical decision making for management of Pre-Eclampsia / Eclampsia severe was conducted and a
simulation on anatomical model of resuscitation of the newborn to evaluate practices provider.

§3.2 Samples Provided
3.2 .1 Health Facilities
All hospitals and health centers providing maternal and newborn care services in the country were identified
in a recent study by the United Nations Population Fund and Adverting Maternal Death and Disability No.7 who
covered by 147 hospitals and 147 health centers in 22 regions of Madagascar. The total number of births in each
formation in 2009 was obtained by the United Nations Population Fund and Adverting Maternal Death and
Disability from registers of health facilities. In addition to being a hospital offering maternal health services
within the meaning of the study of the United Nations Population Fund, a health facility must have an average of
two or more deliveries per day to be included in the Quality study Care. A total of 33 health facilities, hospital
center as well as health centers, met these criteria. The Care Quality Survey has consisted in identifying dealing
formations more than two deliveries a day. Three other training demonstration districts of integrated maternal and
child health program were added, giving a total of 36 courses in 15 regions of Madagascar (see Appendix A for a
list of formations participating in the survey).

3.2.2 Health Agents
For sampling, we chose to work five health workers and Childbirth Prenatal care providers and five in each
health center. In formations with less than five providers, all providers were included. In formations where more
than 5 Job Providers and Childbirth Prenatal care providers and 5 were in office and present, investigators have
been instructed to proceed by stratified sample. We have compiled a list of all AS assistant deliveries and
Antenatal Care by category (doctor, midwife, etc.). Then a sample was taken randomly and proportionally to the
total numbers in each category providers.

3.2.3 Consultation of Labor and childbirth and Prenatal Care
It plans to observe up to 295 births and 295 consultations prenatal care at all (the minimum number set in
surveys Quality of Care of other countries was 250). This figure was achieved as follows: the total number of
births in the 33 initial health facilities in 24 hours amounted to 126 if we go by the number of cases per day. The
observation period was 16 scheduled hours per day and the number of deliveries must occur in these 33 courses
during this period was estimated at 84. Investigators were instructed to stay 3.5 days in training to achieve the
total number of planned deliveries. The number of cases than we expected to observe in each facility
corresponded to the number of deliveries per day, multiplied by two-thirds (for 18 hours) and 3.5 days.
Investigators were instructed to observe the same number of prenatal consultation and deliveries. It is expected
that a small number of maternal and neonatal complications were to be observed.

§3.3 Data Collection
Seven teams of investigators of doctors, midwives and nurses - have been trained and employed within the
framework of the study (21 investigators were trained and 19 engaged in data collection). Each team consisted of
a chief (a clinician having higher qualifications) and two other investigators. During the 11 days of training,
investigators retrained on the knowledge and skills Obstetric Neonatal Care and Emergency, studied the content
of data collection instruments to the master and learned to use a Smartphone to record observational data and to
obtain informed consent from participants. The training included several years to promote the agreement between
observers of clinical benefits to a concordance rate of 80%. Participants observed trainers practicing key
interventions on anatomical models. Trainers deliberately made mistakes during the simulations. The scores given
by participants were then compared to the corrected as determined by the trainers who had designed and
presented simulations. These exercises were followed by group discussions aimed at ensuring that both parties
had understood how to record the data. After training, the investigators did a pre-test in the first academic medical
center and several other clinics in Antananarivo.
Data were collected using HTC Smart Phones, Windows Mobile 6.0 and Pocket PC Creations 6.0, a software
platform for the data entry program. The phones data input masks had logic controls, jumps and consistency
incorporated forms. Each device was equipped with a Secure Digital memory card for data backup. Investigators
had to perform data backup phone every night. At their weekly return to department office from the field, they
gave all their mobile devices to IT Manager / Data that takes care of loading data into the central computer. A fact
sheet on the use of smart phones has been developed and distributed to investigators. It stayed 3.5 days in each
formation to observe care and collect data. Observation of consultations prenatal care was usually performed in
the morning. The deliveries were observed during two consecutive guards 8 hours (16 hours a day). The data on
36 health facilities were collected in September and October 2010.

3.3.1 Management and Data Analysis
At Integrated Maternal and Child Health Program, all files of each data collection instrument were combined
into a single database. During the clearance data, the number of parties represented in each database has been
assessed and beaches have been reviewed to detect any implausible value or average. The final data sets were
uploaded to a website and the results were presented in the form of web tables using the Cold Fusion software
according to a tabulation plan created for all countries using the same instruments. Data analysis has seen the
creation of composite variables "percent complete" way for multi-item correlation. Regarding the observation
data of Labor and childbirth, weightings were applied to databases relating to earlier cases sets of deliveries of
health facilities. The weights were the ratio between the expected and actual proportions deliveries per day (see
Appendix A). The results presented refer only to the sample of 36 health facilities in general.

3.3.2 Approval on Ethics Plan
The study was approved by the Ethics Committee of the Ministry of Health in Madagascar and the
Independent Ethics Committee of the Faculty of Public Health Johns Hopkins Bloomberg. Upon arrival at the
facility, the investigation team handed a letter from the Ministry of Health describing the study managers and
requesting their cooperation. They had to obtain written informed consent from each head of clinic and informed
oral consent from all respondents and observed providers, with women whose work and consultation or childbirth
prenatal care was observed and in some cases, from members of family.

Chapter 4 Results
§4.1 Actual Samples
Most of the 36 health facilities visited were state / public (29 or 81%), four were private (11%) and for
profit, two (6%) were confessional and one (3%) were military. University hospitals, it has 14% of the sample.
Regional hospitals (11 or 31%) and district hospital centers (10 or 30%) accounted for one-third of each sample
and basic health centers two (CSB2) (9 in number) represented a quarter of the sample.

6%

3%

14%

25%

11%
11%

31%
19%

University Hospital Centers

81%

Regional Hospital Centers
District 1 Hospital Centers
District 2Hospital Centers

Public

Private/for Profit

Confessional

Military

Basic Health Centers 2

Figure 4-1. Affiliation Type and Type of Health Facilities Evaluated (N = 36)
Overall, the investigators observed 323 consultations of Antenatal Care (ANC) and 347 cases of Labor and
Childbirth and interviewed 139 service providers. During Antenatal Care observations, they observed only 76
service providers and 148 during Labor and Childbirth observations. These are midwives who have most often
been observed and interviewed (between 64 and 70% of the three groups of samples). "The other doctor’s
providers" represented a quarter of the sample (24%). During Labor and Childbirth observations, they accounted
for only 12% of providers reported and 4% in the Antenatal Care observations. During Antenatal Care
observations, "other non-physician providers" accounted for 30% of the providers. Obstetricians and nurses have
rarely participated in the survey (1.5 to 7% and 4-7%, respectively) in all samples.

Table 4-1. Characteristics of Service Provider and Health Center Sampled
CARACTERISTIC

ENATAL CARE
ERVATION (N = 323)

OR
AND PROVIDERS
CHILDBIRTH
INTERVIEW (N
OBSERVATION(N = = 139)
347)

Midwives

70,3%

68,9%

64,0%

Obstetrician

1,5%

6,6%

1,4%

Other Physician

4,0%

12,1%

23,7%

Nurse

4,3%

3,7%

5,8%

Other

19,8%

8,1%

4,3%

Single Provider (N)

76

148

139

Public

84,2%

81,3%

75,5%

Private, for Profit

8,0%

11,8%

12,9%

ONG

0,0%

0,0%

0,0%

Confessional

7,7%

4,3%

7,2%

Military

0,0%

2,9%

5,0%

University Hospital
Centers

27,6%

35,2%

12,9%

Regional Hospital Centers

27,6%

24,5%

33,1%

District
Centers

2

Hospital

15,8%

14,7%

23,0%

District
Centers

1

Hospital

9,3%

6,6%

10,1%

19,8%

19,3%

21,6%

Category

Affiliation

Type of Health Center

Basic Health Centers 2

Observations and interviews were conducted mainly in Public Health Centers (76-84%). The private for
profit accounted for only 8-13% of the samples. Confessional Health Centers represented 4-7% and Military
Health Centers represented 3-5%. In terms of type of Health Centers, 28% of Antenatal Care observations, 36%
of Labor and Childbirth observations, but only 13% of interviews were conducted in University Hospital Centers.
If the interview data covered a third (33%) observations were performed in Regional Hospital Centers, the
observational data indicate a slightly lower number (25 to 28%). The same case came for District Hospital
Centers. Basic Health Centers accounted for about a fifth of each sample. Most of Labor and Childbirth
observations (63%) were performed in Hospital Centers having fewer than 2,000 Labor and Childbirth per year.
Some (13%) were between 2,000 and 2,999 Labor and Childbirth per year and a quarter (24%) were 4 000 Labor
and Childbirth or more per year.

4.1.1 Characteristics of Service Providers Interviewed
One hundred and thirty-nine (139) providers were interviewed. Respondents were mostly women (86.3%)
and were generally experienced and of a certain age. More than half of them had worked for a period of 10 years
from the end of their initial training (54%) and 59% were aged 40 years or older. Almost all were providing
Antenatal Care (78%), care related to childbirth (90%) and neonatal care (86%). Half of the respondents reported

having attended over 100 births in the last 6 months (51%). Only 18% received some form of technical support or
supervision in the last three months. Two fifths of providers (42%) did not receive any form of supervision.

4.1.2 Sample characteristics for the Antenatal Care Observation
In all, 323 Antenatal Care consultations were observed. One third of the observed Antenatal Care
consultations (38%) were for first pregnancies and 62% to multigravidas. In addition, a third (34%) of Antenatal
Care observations was initial consultations and 66% of follow-up consultations. The average length of a first
consultation was 27 minutes and follow-up visits were 17 minutes. Given that the bulk of the consultations were
follow-up consultations, most of Antenatal Care observed consultations was for women who were in their 21st to
36th week of pregnancy (70%), a fifth was in their 20th week or less (19%) and 11% was at an advanced stage of
pregnancy, i.e. in the 37th week or more. Regarding the outcome of the Antenatal Care consultations, 12% of
clients were admitted to the health facility or referred elsewhere for further care.

4.1.3 Sample Characteristics for Labor and Childbirth Observation
The investigators observed between three and eighteen Labor and Childbirth in each Health Center. The
university hospital center in the capital was an exception with a higher number of cases, specifically 64.In total,
the observations focused on 347 cases of Labor and Childbirth. The number on each observation studied was
variable. 268 first customers’ exams were observed, 255 cases of first stage of Labor and Childbirth, 288 cases of
second and third stages of labor and 336 cases of immediate newborn care and postpartum care. A total of 15
cases of support for suspicion of PPH, 10 cases suspected of Pre-Eclampsia / Eclampsia and 49 neonatal
reanimations were observed. Among the Labor and Childbirth observed, 12% were caesarean and 4% of assisted
Labor and Childbirth. A third of Labor and Childbirth were for first pregnancies (31%). In terms of outcome for
the mother, when virtually all births, the mother went to rest room (92%), 1% of the women were referred in the
health facility, 4% were referred to the block operating within the same health center and 3% were referred to
another health center. No maternal deaths were recorded in the observed cases. Regarding the outcome for the
newborn, three quarters (77%) of newborns went to the maternity ward with the mother, 12% went to the
neonatology department, 4% were referred to a specialist in the same hospital, 2% were referred outside of
hospital and 5% died (18 cases out of the 339 with available information about the future for the newborn).

§4.2 Availability of Drugs and Essential Supplies
4.2.1 General Evaluation of the locations and Health Centers’ Infrastructure
Most of the health center hospitals were equipped with 25 beds or less (72%) and only 6% (N = 2) had more
than 50 beds. More than two thirds ensured a permanent 24 hours and the investigators observed either employee
scheduling or the staff themselves on site (69%). Less than two thirds of facilities had the capacity to perform
operations under general anesthesia (61%). All formations were equipped with electricity powered either by an
electric network or by a fuel-walking generator. If a third party had a water source (39%), only 25% had a water
source located within 500 meters of the hospital. Half of the formations were equipped with communications
equipment and emergency transportation. Almost all (97%) had toilets in working facility, and in 83% of them,
the toilet was in working facility and improved type.

4.2.2 Availability of items for Ensuring Quality of Childbirth
A high proportion of courses available inventory necessary to Infection Prevention is (83.0%). Regarding
sterilization products, average score on all health centers was 66%. This rate was 68% for the equipment of the
delivery room. Blank partographs were available in more than two thirds of the facilities (67%).However; they
were often not accompanied by guidelines. Only about a quarter of the hospitals (28%) had guidelines for normal
childbirth and 28% of directives relating to emergency obstetric care. On articles of Infection Prevention, the
availability of soap and water for hand washing, a sharps container and the decontamination solution was high in
the visited formations (86 to 100%). However, only half of the facilities (53%) were equipped with running water
or buckets fitted with a tap and two thirds (64%) had clean or sterile gloves. As for sterilization items, most

facilities (83%) were equipped with electrical and non-electrical roadworthy and availability of an automatic
timer in working or paper TST indicator was relatively good (64%). However, only half (50%) had hospital
protocols or written directives (losses) on sterilization. Regarding the facilities in the childbirth room, all facilities
were equipped with a table or childbirth bed (100%) and two thirds (63%) of a gynecological examination lamp
condition. In one third of health facilities (33%), the room offered no privacy or confidentiality. Another third
(36%) had a private room ensuring privacy and confidentiality; 22% of facilities were a shared bathroom, and a
room with only privacy was noted in 9% of health facilities (not shown in table).

83%

Supplies struggle against infections [1]

66%

Sterilization Supplies [2]

68%

Equipment of delivery room [3]

75%

Permanence 24h / 24 to Prenatal Care
(Presence or on call)

67%

Blank partographs
Guidelines for normal delivery or
Obstetric Neonatal Emergency Care

28%
0%

Note:

N

20%

40%

60%

80%

100

=36
Figure 4-2 A high proportion of courses available inventory
necessary to Infection Prevention

1 Average percentage for hand washing, the presence of running water or a bucket with tap, a sharp-box,
decontamination solution and sterile gloves (clean)
2 Average percentages for an electric sterilizing equipment or not roadworthy electric (electric autoclave
sterilizer electric dry, electric boiler, or non-electric cooking pot with a lid and heat source), timer or completion
of sterilization indicator, written protocols or guidelines for sterilization or disinfection
3 Average percentages for rooms ensuring privacy and intimacy, a lamp for gynecological examination (or
torch), a table or delivery bed.

§4.3 Essential supplies for Normal Childbirth and Delivery with
Complications
Essential supplies for normal delivery and birth with complications (excerpted and adapted from the
Evaluation of the Provision of Services), - common complications and severe complications - were available in

two-thirds of health center (63 to 67% respectively) (Figure 3). The availability of essential supplies for
newborn care was lower, amounting to half the hospitals (53%).Among the supplies essential for normal
delivery and birth with complications, availability of sterile scissors or blade and suction apparatus for use with
a catheter was relatively good (66-81%) while the clips or clamps for disposable umbilical cord and skin
antiseptics were available in about half of facilities (43-58%). Regarding medicines and supplies for common
complications, availability of an injectable uterotonic (oxytocin or ergometrine) and needle holders was
relatively good (78-81%). The availability of syringes and needles (61.1%), the IV infusion sets (56%) and
needle with suture material (42%) was somewhat lower. Among the drugs and supplies for serious
complications, nearly three quarters of training (72%) had an injectable anticonvulsant (diazepam or
magnesium sulfate). Injectable antibiotics (ampicillin and gentamicin) were available in 61.1% of formations.
About half of the hospitals were not had certain essential neonatal care products: pliers or clamp to
umbilical cord (available in 42.9% of training), towel or blanket to wrap the baby (35%) and incubator in
working order or other heat source (57%). Less than half of the health centers (42%) assessed for maternal
deaths or deaths and missed only near a third of health centers evaluated the neonatal deaths or deaths missed
near (33%). Concerning the management of neonatal sepsis, more than half of health centers had ampicillin
stock (58%) and gentamycin (56%) (Not shown).

Essential supplies for childbirth [1]

62%

Drugs and supplies for common

63%

complications [2]
Drugs and supplies for serious
complications [3]

67%
53%

Supplies for essential care of the newborn [4]
Review of maternal deaths or maternal
deaths near misses

42%

Periodic review of neonatal deaths and
neonatal deaths near misses
0%

20%

33%
40%

60%

80%

100%

Figure 4-3. Essential Supplies for Normal Childbirth and Childbirth Complications With and For Neonatal
Care Essentials
Note: N = 36
1 Average percentage sterile scissors or blades, son and disposable clamps, suction devices for use with
catheter, skin antiseptic and antibiotic eye drops for newborns
2 Average percentages for syringes, needles, oxytocin or ergometrine injection needed to IV, suture
equipment with needle and needle holder, oral antibiotic (cotrimoxazole or amoxicillin)
3 Average percentage for injectable anticonvulsant (diazepam or magnesium sulfate) and injectable antibiotic
(ampicillin and gentamicin)
4 Average percentage for disposable files and clamps, towel or blanket to wrap the baby, sterile scissors or
blades

§4.4 Signal Functions of Obstetric and Neonatal Care Emergency
Performed Complete Course in Last Three Months
A high proportion of health centers reported providing four signal functions over the last three months:
parenteral antibiotics for pregnancy-related infections (92%), parenteral oxytocin (89%), neonatal intensive
care (86%) and manual removal of placenta (83%). However the use of some other indicator functions was
lower. A little more than half of the hospitals offered assisted delivery (56%) or the use of parenteral
anticonvulsants for Pre-Eclampsia / Eclampsia (53%). Only a third had completed product design retention for
contraception (33%). Regarding Obstetric Care and Emergency Neonatal complete, caesarean sections were
performed in two thirds of hospitals (64%) and blood transfusions in half (53%).

parenteral antibiotics

92%

oxytocics parenteral

89%

Newborn reanimation

86%

Manual removal of placenta

83%

caesarean

64%

assisted childbirth

56%

Transfusion sanguine

53%

Using against drug seizures for Pre-Eclampsia /
Eclampsia

53%

Extracting retention product design

33%
0%

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Note: N= 36
Figure 4-4. Proportion of Centers Having Reported They Have Moved the "Signal Functions" During the Last
Three Months.
Between 60% and 68% of centers had drugs, supplies and equipment required for signal functions in the
placenta retention, for administration of parenteral antibiotics, parenteral oxytocic drugs and anticonvulsants
for parenteral manual removal of the placenta, and for the newborn resuscitation (the average percentage result
is shown in Figure 4). For the 23 centers that offer caesarean section, the average percentage score for
medicines, supplies and equipment and the availability of personnel capable of performing caesareans was
higher than 81%.
The placenta retention is extracted manually or by curettage. Placental fragments in detention, or
detention in product design after an incomplete abortion, can be extracted either by curettage or manual
vacuum aspiration. The drugs, supplies and equipment to extract the placenta retention, such as Kit uterine
manual vacuum aspiration, the dilation and curettage kit, available and in working order in half the centers
(50%). Taken separately, uterine manual vacuum aspiration was available in 38% of the centers while the
expansion kit and curettage was available in 36% of centers.
As for drugs, supplies and equipment for injecting parenteral antibiotics to fight against infection,
ampicillin or gentamicin injection, syringes and needles were available in nearly two thirds of the centers (61
%) as Ringer's lactate, infusion or NS D5NS were available in more than half. As for drugs, supplies and
equipment for the use of parenteral anticonvulsants, magnesium sulphate, diazepam, or phenytoin were
available in nearly three-quarters of the centers (72%).
The first line of treatment, magnesium sulfate, was available in 47% of centers in the service of labor and
childbirth.As for the drugs, supplies and equipment for manual removal of the placenta, oxytocin or injectable
ergometrine was available in 78% of centers and ampicillin for injection in more than half of the centers (58
%). Regarding the drugs, supplies and equipment for resuscitation of the newborn, suction pears were very
common (85%), suction devices for use with catheters, tubes and masks (infant size) were common (63%), and
balloons and masks (size 00, 01) were available in half of the centers (50%) only.
In the 23 centers offering cesarean section, the following items were widely available: surgical tables,
lighting, cleaning area adjacent to the operating room and instruments sterilized ready for use (each 96%). In

half to more than two thirds of the centers, halothane (64%), ketamine (57%), health care providers and
anesthetists were available to perform Caesarean sections 24 one 24 (70% each).
64%

60%

MFE for the placenta retention [1]
MFE for parenteral antibiotics Injection [2]
MFE for parenteral oxytocics [3]

65%
63%

MFE for anti-convulsive parenteral [4]

68%

MFE for manual extraction of placenta [5]
64%

MFE Newborn the reanimation [6]

81

MFE and Staffing for cesarean section [7]
0%

20% 40%

60%

80%

100%

Figure 4-5.Drugs, Supplies and Equipment (MFE) For Signal Functions
Note: N = 36, except N = 23 for cesarean
1 Average percentage for withdrawal aspiration, dilation, curettage, oxytocin or injectable ergometrine
2 Average percentages for ampicillin and gentamicin injection, syringe and needle, Ringer's lactate, or D5NS
NS infusion
3 Average percentage for oxytocin or ergometrine injection syringe and needles, Ringer's lactate, or infusion
D5NS NS
4 Average percentages for magnesium sulfate, injectable diazepam or phenytoin, syringe and needle, Ringer's
lactate, or NS D5NS infusion
5 Average percentage ampicillin for injection, injectable oxytocin or ergometrine
6 Average percentage ampicillin for injection, injectable oxytocin or ergometrine
7 Average percentage operating table, lamp, required anesthesia, adjacent laundry area or in the operating room,
tray, drum, or package with sterile instruments ready for use, ketamine, presence of an agent health capable of
performing a caesarean 24 hours 24 (employment of the observed time), the presence of an anesthesiologist or
guard round the clock (the observed time employment)
As for specific drugs, oxytocin was available in three-quarters of the centers (78%). Magnesium sulfate
was available in less than half of these centers (47%), and the items required for the administration of
magnesium sulphate, calcium gluconate and lidocaine were available in half of the centers (53% and 51%,
respectively) (Figure 6). Antihypertensives were available in half of the centers (50%). However, sedatives
(phenobarbital) were available in a quarter of centers only. According to the guidelines, sedatives should not
be used.

Magnesium sulfate

47%

Calcium gluconate and lidocaine for MgSO4

53%

Antihypertensive

50%

Sedatives (phenobarbital)

25%

Oxytocin

78%
0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Note: N= 34

Figure 4-6. Additional Items availability for Signal Function
The study evaluated the availability of tests and services relating to prenatal care systematically
offered. Thus, counseling HIV / AIDS was systematically offered in 94% of centers, while counseling
and voluntary testing was available in 82% of centers (Figure 7). The tetanus vaccine was also available
on the day of the visit in 91% of centers. The blood screening for syphilis was available in 88% of centers
and counseling on family planning in 71% of centers. However, sulfadoxine-pyrimethamine (SP) for
intermittent preventive treatment was systematically proposed only slightly more than half (56%) of
centers, as was urinary protein test. It has been reported that urine tests for glucose were routinely offered
in 32% of the centers while the blood grouping was proposed in 24% of centers.

Counselling for HIV / AIDS

94%

test toxoid

91%

Serological screening for syphilis

88%

Counselling et dépistage volontaire

82%

Counselling PF

77%

Urinary protein test

56%

Sulphadoxine perméthryne for TPI

56%

Urinary glucose test

32%

Blood typing

24%
0%

10%

20%

30%

40%

50%

60%

70%

80%

90% 100%

Note: N= 34

Figure 4-7. Elements of Prenatal Care Systematically Offered
The essential basic items for Prenatal Care were available in 82% of centers (average percentage score for
5 items, not shown). Almost all centers had a fetal stethoscope (97%), and tetanus vaccines (94%). A blood
pressure in working was available in 82% of centers, and iron / folate tablets were available in 77% of the
centers while the SP for intermittent preventive treatment was available in 62% of centers. As we have already
pointed out before, the guidelines often lacked in the health facilities. The guidelines or protocols for Prenatal
Care and Sexually Transmitted Infections (STIs) were available in only 38% of centers, while the guidelines
for the management of Pre-Eclampsia / Eclampsia were rarely available (15%). Urine test strips or the ability
to make boiled urine tests were also missing in some centers (29%).
The items necessary to quality counseling Prenatal Care was available in 54% of centers (average
percentage score of the two articles). Guidelines or protocols for Prenatal care generally lacking (38%);
however, visual aid for educating clients on matters related to pregnancy and SPN were more available (71%).
The items required for Infection Prevention were more or less widely available (82% average percentage
score of five articles). All centers had containers or sharp objects piercing and 94% had soap for hand washing.
Water for hand washing was available in 79% of centers and clean latex gloves were available in 71% of
centers. Premixed decontamination solutions were available in 65% of the centers.
The items required for medical examination were available in two-thirds of the centers (67% on three
articles). While almost all the centers had a table or bed for deliveries (94%), two thirds of the centers had
private rooms for privacy and confidentiality (65%) and 41% had a projector for gynecological examinations.

§4.5 Knowledge and Skills of Health Care Providers
Providers had scores ranging from 34% to 68% in ten areas to multiple points of the Maternal and
Newborn Health. Providers have obtained higher marks for examinations and necessary followed for Labor
and Childbirth (66%), such as the location of tears and lacerations (68%), and the first test and evaluation of
women with postpartum discomfort signs within 72 hours (63%) Most providers (73%) correctly answered the

question on the document where you have to record all the activities and observations ("partogram"). Providers
have obtained lower scores for signs for evaluating Hyper Privea Placenta (56%). Few providers knew the
actions and tests to do in case of weakness of the uterus (39%). The scores were also low for labor signs of
obstruction (45%), equities and tests to do before a case of obstructed labor (37%), and actions, testing and
interventions to do on a woman with postpartum discomfort within 72 hours (34%), although providers have
obtained higher scores on the first test and evaluation for a woman with postpartum discomfort, as noted
above. The lowest score was for knowledge in preventing transmission of HIV from mother to child
(Prevention of transmission Mother and Child) (14%). Overall, the average score for knowledge in the ten
areas of Maternal and Newborn Health, with the exception of the Prevention of transmission (of HIV) Mother
and Child, was 52%.

Malaise postpartum : actions, tests,…
Discomfort within 72 hours post partum: tests…

63%

Obstruction of work: actions and tests [8]

37%

Obstructed labor: signs [7]

45%

Products / placenta retention: actions and tests [6]

36%

Hyper Placenta Praevia: actions and tests,…

39%

Hyper Placenta Praevia: Any tears and…

68%

Postpartum hemorrhage: assess signs [3]

56%

Prevention of transmission (of HIV) Mother…

14%

Partograph: recording observations

73%

Exams & followed up for Labour and Delivery…
0%

66%
10% 20% 30% 40% 50% 60% 70% 80%

Figure 4-8. Average Score for Knowledge of healthcare Providers
Note: N = 138
1Mean percentage for the following steps: monitoring the fetal heart rate, assessing the degree of molding,
assessment of cervical dilation, evaluation of the descent of the head, followed by uterine contractions,
monitoring blood pressure of the mother, followed pulse of the mother, monitoring the temperature of the
mother, checking urine, meconium in the amniotic fluid research.
2Mean percentage for the following steps: counseling on prevention of transmission (of HIV) Mother and
Child, antiretroviral prophylaxis in early labor, wiping the nose, mouth and eyes of the newborn with gauze,
avoid sucking, no routine episiotomy, minimizing deliveries instrument; cleaning the vagina by hibitane;
minimize vaginal examination; minimize artificial rupture of membranes; avoid milking the cord / clamp the
cord immediately; appropriate use of the partograph; Active Management of the Third Period of Childbirth;
antiretroviral prophylaxis to the newborn
3Average percentage for the uterus unconstructed and weakness of the uterus; rapid or weak pulse; volume of
external bleeding; retention of products of conception and placenta; injuries to the genital tract; pallor; check if the
bladder is full.

4Average percentage anterior part of the urethra, vagina, cervix, perineum
5Mean percentage for the following measures: to reassure the woman, massage the uterus, bladder
emptying, administer uterotonic IM or IV effector bimanual compression of the uterus, perform an abdominal
aortic compression, start liquids IV, draw blood for typing and cross-matching, prepare for the operating room if
blood does not stop, refer to the doctor or hospital, take up the footboard
6Mean percentage for the following measures: to reassure the woman, empty the bladder, repeat
administration of uterotonics, manually remove the placenta / product design, give IV fluids, check vital signs
for impact, check contraction uterus, massage the uterus after removal, give antibiotics, draw blood for typing
and cross-matching, prepare for the operating room if blood does not stop, refer to the doctor or hospital
7Average percentage for any signs of descent or presentation of a body part, no change in the dilation of
the cervix; ring Bandl, severe modeling, first stage> 12 hours, second stage> 2 hours
8 Mean percentages for the following measures: to reassure the woman, start IV fluids, continuous bladder
drainage tube, prepare for Caesarean call the doctor or refer, give parenteral antibiotics, draw blood for typing and
cross-matching, monitoring vital signs
9Mean percentage for the following measures: assess vaginal bleeding, check the pulse (rapid / weak), look
for a high fever, check if there are low blood pressure, check if there is pain or abdominal tenderness, check for
smelly vaginal discharge, check for anemia and perform a quick test to diagnose malaria
10Mean percentage for the following: start IV fluids, administer parenteral antibiotics, administration of
analgesics / antipyretics, make endometrial samples, have an ultrasound, start antimalarial treatment if the test is
positive perform manual vacuum, refer to physician or hospital.
A question was not some recommended practices and the need or not to use each of them systematically
at work (not shown). Among the interviewees, 99% gave the correct answer ("false") for episiotomy, 95% for
artificial rupture of membranes, 90% for enemas, and 76% for shaving pubic, but only 47% for suctioning the
nose and mouth of the newborn, which means that half of the providers still believe that the aspiration of the
nose and mouth of the newborn is a systematic practice.

4.5.1 Pre-Eclampsia / Eclampsia Fictitious case
Data on a fictitious case of a woman who has a Pre-Eclampsia and Eclampsia was read aloud.
Respondents were given a printed copy of the case study so that they can follow the reading. The average score
for the first section, the elements of medical examination, was 66%. Almost all respondents recognized the
correct diagnosis of severe preeclampsia (96%). Taken together, the average score for the examination and
diagnosis was 70%. Yet only one third of respondents mentioned the mother's stabilization steps with
magnesium sulfate and antihypertensives (33%). Respondents had an average score of 47% for the first stages
of the care of a woman with severe preeclampsia and an average score of 50% for the proper management of
seizures. Similarly, half of the respondents knew what the equipment and essential supplies that should be
available to the referral center (56%). Only a third of respondents (30%) were aware of the actions to be taken
an hour later. For all respondents, the score in the case study was 51%.

4.5.2 Resuscitation Simulation of a New Born
Providers had to perform a simulation to three parts of resuscitation of a newborn on an anatomical
model provided by the interviewer. More than half of providers (57%) showed how to properly perform all the
steps: drying the newborn, place it on a hot surface, keep the head in a slightly extended position, sucking in
the mouth or in the nose with a balloon or a catheter. For ventilation, a third (34%) of providers showed all
elements correctly (place a proper size mask covering his chin, mouth or nose, squeeze the ball between two
fingers or hands appropriately, and ventilate at a rate of 40 breaths / minute). Two thirds (66%) of claimants

demonstrated adjustments (check the neck position, check the seal, repeat aspiration, and / or higher
compression). The overall score for the newborn resuscitation was 52%.

4.5.3 Prenatal Care Observations
Almost all clients were asked about the presence of a danger sign (90%). However in assessing the
health status of the 11 elements at Antenatal Care, the average score was only 38% (Figure 4.1). In half the
cases or more, providers asked the client if she had vaginal bleeding, if there was a problem that preoccupied if
she had malodorous discharge, if she felt the baby move (50% to 77%). They asked less frequently whether
she had a persistent cough for the past two weeks or more, if she knew her HIV status, if it had convulsions
and lost consciousness, had it big difficulty breathing, or if his hands were swollen her face if she had a
headache, saw blurry or had fever (4-40%). If providers have taken the blood pressure of 82% of the clients
they have done correctly in 48% of cases. On the assessment of preeclampsia, providers interviewed the client
about danger signs or took his blood pressure correctly in only a quarter (25%) of observations. Similarly, only
29% of women have been a urine test, or a reference to this analysis. Claimants advised the woman to return to
the clinic in case of danger signs (headache, blurred vision or swollen hands or face) in 31% of the observed
prenatal consultation. In more than half of the cases (56%), providers discussed the hands of women seeking
edema.

56%

Examined the presence of edema on hands
Advised to return if danger signs related to the
Pre-Eclampsia / Eclampsia [4]
Performed a urinalysis or referred for such
analysis
Asked about the danger signs associated with
the Pre-Eclampsia / Eclampsia and took…
Taken blood pressure following the right
technique [2]

31%
29%
25%
48%
82%

Taken blood pressure

90%

Asked about the danger signs
Rated current health status [1]

38%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%
Note: N= 323

Figure 4.9 Current conditions of Health and Evaluation of Pre-Eclampsia / Eclampsia
Note: N=323
1Average percentage for vaginal bleeding, fever, sore head or blurred vision, swelling of the face or hands,
severe breathing difficulties, convulsions or loss of consciousness, malodorous discharge, question if the client
felt the baby move or not, coughs persistent for two weeks or more, question if the client knows their HIV status
and if there is other problems that it concerns.

2The two research components of Pre-Eclampsia / Eclampsia: question on danger signs and taking blood
pressure according to proper technique
3 Recommend returning in case of headaches or blurred vision, advice return in case of swelling of the hands or
face
In the first prenatal consultation observed, providers administered the tetanus vaccine to nearly three
quarters (70%) of women and have given iron tablets or folic acid than half of them (53% and 54%
respectively). The average score for these two items was 62%.Score as a percentage of providers who
questioned multigravidae clients about their history of pregnancy during the first prenatal consultation was
36%. Providers routinely interviewed clients on cases of stillbirth, abortion and cesarean in the past (71-80%).
If they inquired about neonatal death in half of the cases (57%), they rarely questioned clients about their
history of anemia, convulsions during pregnancy, childbirth assistance, d hypertension associated with
pregnancy, prolonged labor, multiple pregnancy or heavy bleeding after childbirth (1-26%). In almost all raw
prenatal consultation, the provider asked the age of the client, the date of her last period and the number of
previous pregnancies (94-99%) (Not shown).Providers administered antimalarial prophylaxis (Prenatal Care)
in 40% of the observations but were given insecticide-treated nets rarely, that is to say, only 4% of cases. On
average, they administered preventive treatment (iron tablets or the first consultation folic acid, tetanus
vaccine, malaria prophylaxis or MII) in 39% of consultations Prenatal Care observed.

Prevention: iron or folic acid, AT, malaria,
ITNs

62%

Impregnated mosquito net (or the client
already has one)

36%

Malaria prophylaxis

40%

ITN (or client has one)

4%

Preventive: iron or folic acid, TT, antimalarial, ITN

39%
0%

10%

20%

30%

40%

50%

60%

70%

Figure 4-10 First Prenatal Consultation and Preventive Treatments
Note: N = 108 for all clients coming for their first consultation, and N = 60 multiparous coming for their
first consultation. N = 322 for AT, malaria, and ITNs.
Average percentage antecedent of stillborn, heavy bleeding during or after childbirth, cesarean section,
abortion, pregnancy multiplies, prolonged labor, pregnancy-related hypertension, seizures related to pregnancy,
to assisted delivery (forceps, vacuum extraction), anemia, neonatal deaths
In more than two thirds of cases (67-77%), providers gave advice on iron / folate tablets, antimalarial
and tetanus vaccine (Figure 4-11). However, the score is much lower for counseling on pregnancy and

preparation for childbirth (33-35%). The score for counseling on postpartum family planning was also low
(20%).

Counseling on iron / folic acid [1]

67%

Counseling on the tetanus vaccine

77%

Counseling on antimalarials [2]

67%

Counseling on pregnancy [3]

33%

Counseling on birth preparedness [4]

Counseling on postpartum family planning

35%

20%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Figure 4-11 Prenatal Care Advised for clients
Note: N = 322
- Mean percentage for the following: explain the purpose of the treatment, explain how to take it, explain
the side effects.
- Mean percentages for the following: explain the purpose of the treatment, explain how to take it, explain
the side effects.
- Mean percentage for the following: the client about the evolution of pregnancy, tell the client to return if
vaginal bleeding, tell the client to return in case of swelling of the face or hands, tell the client to return in case
of severe headaches or blurred vision, tell the client to return in case of persistent cough, tell the client to return
in case of severe abdominal pain. Mean percentage for the following: ask the client where she will give birth,
advise the client to prepare for childbirth (put money aside, arrange for emergency transportation), adviser
client to use qualified health workers for delivery, discuss with the client the necessary urgency to have at
home (eg, sterile blade).

§4.6 Observations of Labour and Childbirth
Regarding the Labour and Childbirth observation, providers have realized rather regularly the first review
of clients with a result of 71% for all observations of Labor and Childbirth. This score is similar to that
obtained for the component of the second and third stages working practices (76%). Providers asked about half
of the customers if they presented a danger sign during their current pregnancy (55%). However, the average
score for all seven danger signs was 21%. Providers asked 55% of multifarious clients if they showed signs of
danger during their previous pregnancy. Half of all women also received postpartum care practices (54%). The
overall score for the essential practices for the labor and Childbirth observation is 53%.

Among the initial assessment of client issues, good scores on the following points: asking questions to
their clients about their age, pregnancy and parity, perform abdominal examinations with a tape measure,
check the fetal presentation, take fetal heartbeat and perform vaginal examinations (89-93% each). The
temperature and pulse were taken in half of women (46 to 48%), while the urine analysis results were noted or
discussed in 10% of cases reviewed. Issues relating to each type of hazard signs have achieved results ranging
from 10% to 34%. During the second and third steps, providers rather frequently (62-86% each) quietly
supported the baby's head, checked if the placenta and membranes are complete and verified if there
lacerations.

71%

First evaluation of the client - General [1]
Asked if there was any danger signs (average)
[2]

21%

Asked if there was a danger sign (regardless of
sign)

55%

Multipare: asked if there had complications in
a previous pregnancy [3]

49%
76%

Second and third stages [4]
Immediate postpartum care [5]

54%

Essential obstetric practice (average)

53%
0%

10%

20%

30%

40%

50%

60%

70%

80%

Figure 4.13: Essential Practices during Labor and Childbirth

Note: N = 272 for all components except: N = 168 for multiparous and N = 336 for postpartum
care.
1 Mean percentage for the following measures: check the book of the client or ask his age, duration of
pregnancy and parity; take the temperature; pulse; ask Note the amount of urine emitted; measure the height of
the uterus with tape, perform a general examination (search for anemia, edema); perform abdominal palpation:
check fetal presentation by palpation of the fetus; perform abdominal palpation: check the fetal heart rate with a
stethoscope or ultrasound; make a vaginal examination (cervical dilation, descent of the fetus position,
membranes, meconium)
2Average percentage for fever, malodorous discharge, sore head or blurred vision, swelling of the face or
hands, convulsions or loss of consciousness, shortness of breath, vaginal bleeding
3Average percentage for high blood pressure, heavy bleeding during or after childbirth / hemorrhage,
cesarean history, history of stillbirth, abortion, assisted delivery history

4 Mean percentages for the following measures: take vital signs of the mother every 15 minutes after birth;
palpate the uterus 15 minutes after delivery of the placenta
With regard to interpersonal communication, high results were obtained on the following elements:
providers respectfully greeted their customers, encouraged them to be assisted by a person accompanying during
all labor and childbirth, informing pregnant women of the results, administered treatments kindly, and shrouded
women (65 to 88% each). Pretty high scores were obtained for the explanation of the procedures for women, for
the support provided to the person, incitement to walking and strolling or adopt different positions during the
first stage of labor (35 to 49% each) . It was rare that the claimant asks the wife or the person accompanying if
she has any questions (28%). It was noted that the average score for the prevention of infections in general got
was high on the nine elements (74%). Two elements have obtained low scores. In more than half of the cases
(60%),the claimant has placed protective cloths to cover the face, hands and body to prepare women for
childbirth, and in a quarter of the observed cases (26%), the claimant has removed the deck and cleaning with
chlorine 0.5% solution.

Immediate PI for the newborn and postpartum
care [4]

74%

PI during the initial assessment and the 1st phas
e [3]

71%

PAC during the 1st and 2nd phases [2]

63%

PAC during the initial evaluation [1]

60%

0%

10% 20% 30% 40% 50% 60% 70% 80%

Figure 4-14. Interpersonal Communication and Preventing Infections during Labor and
Childbirth
Notes: N = 275 for the PAC during the initial evaluation, N = 262 for the 1st and the2nd stage of labour,
N = 263 for the PI during the first stage of the work, and N = 339for the PI in the newborn and postpartum care
-Average for the following measurements: respectfully greet women, encouraging women to have
someone you trust with it during labour and the birth, ask the woman (and his trusted person) if they have
questions, explain the procedures to the woman (person) before making it, inform the pregnant wife of the
findings.
1Averages for the following measurements: at least once, explain to the pregnant woman and its person of
confidence what will happen during the work. At least once, encourage women to drink and to eat during

labour; at least once, encourage/help the woman to make the market and to adopt different positions during the
work. Support women in a friendly manner during the work, the cover.
2Average percentages for the following measures: wash hands before any examination, wear gloves
which have undergone a sterile or high-level disinfection for vaginal examination; wear protective clothing in
preparation for childbirth with protection of the face, hands and body from contact with body fluids
3Average for the following measurements: throw away sharps in a container resistant to puncture
immediately after use, decontaminate all instruments to reuse in chlorine
at 0.5% solution, throw all waste contaminate,them in a sealed container, remove theaprons and wipe with solu
tion chlorine at 0.5%, carefully wash hands with SOAP and dry them.
4With regard to the control of the planceta, blood has almost always been taken (88%)(Figure 14). The
danger signs were discussed in more than half (55%) examinations. The score obtained for these two elements
are 47%. The test of proteinuria was rarely done (7%). The blood pressure of patients has been recorded at
least every four hours for nearly two-thirds of some patients which data relating to the delivery have been
transcribed on a partogram (N = 89 or 28% of the cases of T & A observed.

blood taken every 4 h

Evolution followed by partogram: voltage

62%

Performs a urine test
Asked if there were PE/E, signs of danger and take
s blood pressure

70%

47%

Takes blood pressure

82%

Immediate PI for the newborn and postpartum care
[4]

55%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Figure 4-15 Control of eclampsia/pre-eclampsia during the work
A partogram was used in one quarter of the T & A observed (28% of 342 births). As shown in Figure 15,
the use of the partogram was started at the right time in only19% of the observed birth. In 14% of the
observations, the partogram was used to record information post partum, including the birth time and the type
of delivery. In the case of births where a partogram was used (see table 3), providers have launched its use at
the time in the majority of cases (from two-thirds to three-quarters of cases) depending on the partogram. They
have recorded blood pressure every four hours in two-thirds of the cases (63%).

However, the filling rate was low for other elements of the partogram and was as low as 5.5% for taking
the pulse of the mother every 30 minutes. In the comments where the line of action has been reached, followup action was initiated in all cases. However, no expert was consulted in all these cases.

Average score

13%

Blood pressure recorded every 4 h

Tracing all the 1 / 2
hours of labour to the min.

17%

2%

Used Partogram and using launched at the rig
ht time

19%

0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%

Figure 4-16. Realization of each of stages of AMTSL during birth observed

Table 4-2. Foreword the Partogram use ticks
Launch The Use Of Partogram At The Right Time By Type

Pourcentage

PARTOGRAM
Partogram of 3cm (who retired)
Partogram of 4cm (who new)

67,3
79,6
77,0

Another partogram
Logging of the following on the partogram at least all the
30 minutes during work
Frequency/duration of the contractions

47,6
34,0
5,5

Heartbeat of the fetus

63,0

Pulse of the mother
Blood pressure log every four hours during labour
Logging of the following on the partogram after

72,0
58,5

childbirth:
Time of birth
Method of childbirth
Appropriate measures to the action thresholds (among the partograms where)
These thresholds have been achieved) (N = 28)
Consult a specialist

0,0
2,2
40,8
30,1
21,3

Notes: Data are for 89 observations of T & A for which a partogram has been used. The sum of the
percentages exceed 100% because it's weighted values
In regards to childbirth, providers have administered a uterotonic (oxytocin) during the third stage of
labour in the majority of cases (85%). Figure 5.5 gives the frequency of each element of childbirth.

70%

Administer oxytocin by appropriate means

Uses of oxytocin

84%

Uses an uterotonic

85%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Figure 4-17. Observation of compliance with all the correct steps of AMTSL during childbirth
Notes: N = 288
Compliance with all elements of the work is shown in Figure 5.6. In 60% of observed cases, oxytocin was
administered properly, be it in terms of dose or route of administration. This figure drops to 21% if it is taken
into consideration that oxytocin should be administered during the first minute. If controlled cord traction and
uterine massage are added to the criteria, only 13% of the cases were in compliance with all elements and
stages of work

(+) Realizes a uterine massage

13%

(+) controlled cord traction

21%

(+) timing, in a time of 1 min

44%

(+) timing, within a period of 3 min

60%

(+) dose and correct units

70%

(+) way correct

84%

Uses a uterotonic using oxytocin

85%
0%

10% 20% 30% 40% 50% 60% 70% 80% 90%

Figure 4-18 Care of newborn
Notes: N = 288

.

The immediate newborn care consist of six parts, and the average score in percentagewas 63% . The frequ
ently made elements include: immediately wipe thenewborn with a dry towel, put aside the wet towel and cove
r the baby of a dry towel, cut the cord with a clean slide, delaying clamping of the cord (71 to
95% each).Providers have rarely helped mothers to breastfeed in the first hour, the result is 37%one third of ca
ses, and the baby was placed skin against skin with his mother in only aquarter of the cases, or 27 percent.

Immediate care of the newborn - medium
[2]

21%

Immediate care of the newborn (USAID)
[1]

64%

0%

10% 20% 30% 40% 50% 60% 70%

Figure 4-19 Practices harmful and not recommended: frequency mean in the comments.
Notes: N = 336
1Average for the following measurements: place the baby skin-to-skin on the abdomen of the mother;
immediately dry the newborn baby with a towel; remove the wet towel and cover with a dry towel. cut the cord
with a blade; help the mother to start breastfeeding within one hour following birth; tie/clamp the cord at the
stop of the beats or 2-3 minutes after birth if not (but not immediately after birth).
2Average for the following measurements. Immediately dry the newborn baby with a towel; remove the
wet towel and cover with a dry towel. Cut the cord with a blade; help the mother to start breastfeeding within
one hour following birth.
At least, harmful or not recommended practice has been accomplished. In the majority of cases observed
(54-60% each). Among these harmful practices, the stretching of the perineum was common (70%). In 30% of
observed cases, the newborn was also held in the air upside down. Other harmful practices were rarer (to use
enemas, shaving the pubic, apply pressure on the uterus, and wash the uterus or slapping newborn) (1-17%
each). Among the non-recommended practices manual exploration of the uterus after childbirth was observed
in half of cases (49%). The use of episiotomy, suction the nose and mouth of the newborn at birth, the
restriction of intake of food and fluids during labour, and other practices, were rarely observed (4%to 22%
each).

54%

Harmful practices - medium [2]

60%

Not recommended practices - average [1]

51% 52% 53% 54% 55% 56% 57% 58% 59% 60% 61%

Figure 4-20 practices harmful and not recommended: frequency mean in the comments.
Notes: N = 339
1Average for the following measurements: manual exploration of the uterus after childbirth, use of
episiotomy, suction of the mouth and the nose of the newborn, restricting food and fluids during labour
2Average for the following measures: use the washing, shaving pubic pressure on the uterus, the uterus
after childbirth washing, slapping newborn, holding newborn head down, milking the chest of the newborn,
manually stretch the perineum.

§4.7 Observations of Cases of Complications
Observers have monitored and recorded 10 cases of PE/E, 15 cases of PPH and 49cases of neonatal resusc
itation data.Summary of taking Charge of cases of Suspicion of preeclampsia/eclampsia observed in
Madagascar (N = 10)

4.7.1 Number of cases and training health
Theobserver has suspected the presence of PE/E in clients and has followed these
cases using the observation of the PE/E module, which gave result nine cases of pre-eclampsia and one case of
eclampsia. These PE/E cases in seven centres assessed; threecases occurred in university hospitals. In one case,
the newborn died, but the cause ofdeath was not known. The summary below shows the availability of drugs i
n thesecentres, the systematic delivery of PE/Emrelevant for the SPN in these centres, support 10 observed cas
es and assumptions in the analysis.

4.7.2 Availability of medicines
Providers not administered magnesium sulphate in none of the cases of PE/E, including the centers which
were in reserve. On the other hand, diazepam has been administered to five of these cases while the
antihypertensive have been administered in at least two cases. In at least one case, antihypertensive were not
administered to clients who ought to receive, even if these drugs were available in the center. Magnesium
sulphate was not administered to a patient with seizures, even if it were available in the hospital. This patient
was also filmed on the side to prevent inhalation and to ensure a good flow between the fetus and the placenta.
In a case of PE, the patient was transferred to another center, although the center of origin (a public hospital
district) ought to be able to support the EP and to proceed to a birth forceps or suction cup, if necessary.

Comments, the use of the partograms were launched in two of these cases only. In any case, the partogram has
been filled properly including the traces of blood. Overall, magnesium sulfate has not been administered in the
case of PE/E, unlike standard procedures, and even if it were available. Blood pressure medications were not
administered in a consistent manner when their administration was relevant and when they were available.
These results are in agreement with the results on the fictitious case of interview by providers, in which the
scores for the support of the EP were low, turned sideways to avoid inhalation and to ensure a smooth flow
between the fetus and the placenta. In case of PE, the patient was transferred to another center, even though the
center of origin (a public hospital district) ought to be able to support the EP and to a birth forceps or suction
cup, needed. Comments, the use of the partograms were launched in two of these cases only. In any case, the
partogram has been filled properly including the traces of blood. Overall, magnesium sulfate was not
administered in accordance with the global guidelines even if this drug was available or has been
recommended, as suggested by the observed cases of administration of diazepam and antihypertensive.
Furthermore, antihypertensives were not administered systematic when they were recommended for the
situation and available manner. This result is in agreement with results obtained in interviews with provider’s
interview on case scenarios, although most providers are able to define and diagnose cases of PE/E, only onethird of them are able to correctly describe the appropriate support.
Table 4-3 Summary of the taking in Charge of cases of Suspicion of PE/E

OBSERVATION

NUMBER OF CASES (TOTAL N = 10)

Patient taken convulsions or unconscious

1

Administered magnesium sulphate

0

Diazepam administered

5

Antihypertensive administered

2

Death of the mother

0

Death of the newborn

1

4.7.3 Assumptions and warning
This analysis is based on 10 observed. For most of these cases, 70 elements, or more, of the
observation grid were missing. When an answer is not marked (that is to say that it is left blank), the element
was supposed to have been done or administered. This analysis also considers that the drugs are not available if
they were noted as not having seen anywhere on the site, even if the providers confirm their availability. There
are four possible variables referring to the administration of diazepam; as soon as one of these variables was
positive, it was assumed that diazepam was administered. In one case, diazepam was stated as having been
administered, yet based on observations; this medicine did not exist in the stocks. Summary of support for the
case of Suspicion of hemorrhage postpartum observed in Madagascar (N = 15)

4.7.4 Number of cases and Centers
The observer has suspected the presence of PPH 15 women and keeps track of these cases using the
observation of PPH module. These cases of PPH have occurred in nine of the 36 centers assessed. Five of these
cases occurred in the University Hospital. The newborn died in three of these cases of PPH and in one case it is
stillborn. The summary below examines the availability of appropriate drugs, equipment and other support
capacity factors in these centers; delivery and completeness of AMTSL in these cases; the support of the 15
cases observed; and the assumptions used in the analysis. It is important to note that apparently the delivery
took place at home or en route to the center in five of these cases, and two of these cases were spontaneous
abortions to mid gestation. These are not all standard interventions of T & A that would have been possible or
appropriate in these seven cases.

4.7.5 Assumptions and warning
This analysis is based on 15 cases observed. For most cases, a large number of elements of the
observation of PPH support grid have not been met. Thus, the assessment of a large number of aspects of QoS
has been difficult. It was not possible to ensure that interventions have not been completed in cases where data
were missing. In addition, interventions should not or could be carried out in cases of abortion or delivery
outside health centers. Because of these deficiencies, and because cases of PPH include a large number of
clinical situations, statements in number of cases below, where correct interventions have been completed,
should not be interpreted as percentages.

§4.8Availability of Medicines
All centers, with the exception of one, had oxytocin and ergometrine in stocks of their pharmacy.
Oxytocin was available in the maternity of seven of these nine centers service stocks, and ergometrine was
available in the maternity of three of these nine centers service stocks. In contrast, misoprostol was available in
only two stocks of pharmacies in these 9 centers as well as in two of these nine centers maternity services
stocks. The guidelines for the T & A have been seen in only two of the nine centers where PPH have occurred.
The guidelines for emergency obstetric care were observed in four centers. The maternity of five of these nine
centers services lacked means to administer the IV or valued supplies, or more (examples: syringes, sutures).
Five of the nine centers were able to make blood transfusions, had a blood bank, and had achieved a
transfusion in the past three months. Two other centers could make blood transfusions but did not blood bank.
The eight women had their work that have given birth in the center, it was observed that in one case only, the
claimant commenced a partogram use and the only information available was the outcome of childbirth and
pregnancy.

4.8.1 Education and Interventions Additional Postpartum
Despite the wide availability of oxytocin, the uterotonic was administered only after childbirth in all just
four of the eight cases in which women were in labor and gave birth in the center (excluding cases of
spontaneous abortion). Oxytocin has been used in four of these cases. Oxytocin was administered in the first
three minutes of childbirth in three cases, and in the first minute of childbirth in the latter case. Oxytocin was
administered by intramuscular injection in three cases, and by IV in a case. In three cases, providers have
exerted controlled cord traction. In three cases also, the client received a uterine massage. All of the three
elements of the AMTSL have been made in-two cases only. Examination of the completeness, the placenta and
membranes made in three cases; the existence of laceration of vagina and perineum audit been conducted in
four cases. For two cases of fetal miscarriage to mid gestation term, the claimant was administered oxytocin to
the client in one of these two cases, after the appearance of the front of the shoulder.

4.8.2 Post Partum Support
In nine of the 15 cases of PPH, the woman was informed of what was happening, and providers it were
reassured, as well as those accompanying him. In five other cases, only one of these actions only was made. In
one case, there has been no communication of information between the claimant, the woman and those who
accompanied him. In 15 cases post partum, only four received the uterotonic agent in treatment; oxytocin has
also been used in all these cases. Manual removal of the placenta appears to have been attempted in four cases;
in at least four of these cases, this extraction was not performed in accordance with the directives or at least an
important step been omitted (example: FT). In both cases, women did not delivered in the Center, it has been
referred to the center and seemed to need a manual removal of the placenta, but apparently this has not been
attempted or completed. It is difficult to comment on insurance with additional aspects of the quality of the
support of PPH cases because of incomplete data (example: suturing of lacerations, bimanual compression).
Nevertheless, it seems that the claimant was preparing to perform a transfusion in one case, even if ultimately
no transfusion was made (despite the ability of the center to do so). Four cases, reported that the woman was
prepared to be operated in the same center. Among these cases, a woman has been referred to another agent of
health from the same center, instead of being operated. The reason for this decision is unclear. According to
the available data, three women were carried out in the same Center, yet one was recorded as having been
prepared to be operated in the same center. Information is not clear and are insufficient: maybe other women
have been made after have been prepared.
Overall, it appears that providers have need of more support and supervision to ensure the full benefit of
the interventions of AMTSL. For example, only half of women who have given birth in the center received a
uterotonic agent in treatment. Although oxytocin was available in the maternity service stocks in four cases, it
was not administered (three of these cases have occurred in the same center). In addition, providers did not
have uterine massage and have not exercised traction controlled in most cases, even if these interventions do
not require specific supplies and equipment.
Table 4-4 Summary of support for the case of Suspicion of PPH

OBSERVATION

NUMBER OF CASES (TOTAL N = 15)

AMTSL interventions completed *.
Administration of a uterotonic

4

Controlled cord traction

3

Uterine massage

3

All the interventions of AMTSL

2

Type of treatment provided
Administration of a uterotonic

4

Massage of the uterus

5

Repair of lacerations

2

Manual removal of the placenta

5

Bimanual compression

--

Blood transfusion

0

Issues
Surgical operations

3

Maternal deaths

0

Perinatal death

4**

Chapter 5 Other Cooperation of Department
Management Health
The United Nations Population Fund or UNPF is an international development agency that promotes
the right to health and equal opportunity of every woman, man and child. . The United Nations Population
Fund supports countries in using population data in the formulation of policies and programs to reduce poverty
and to ensure that every pregnancy is wanted, every birth is safe, everyone is protected from Human
immunodeficiency virus and that all newborns and all the women are treated with dignity and respect.
According to the United Nations Population Fund strategic plan for 2008-2013, the Fund's focus areas are
population and development, reproductive health and gender. The health management department and The
United Nations Population Fund signed in 2011 cooperation program covering the period 2008-2011. The
signing came after the adoption of the Action Plan for Madagascar, the strategy paper for reducing poverty in
the country for 2011-2014. The program was also aligned with the new Plan of the United Nations for
Development Assistance Framework for the period 2008-2011. The interventions of United Nations
Population Fund program covered: access of the population (and particularly of the most vulnerable groups) to
quality services in reproductive health and family planning, service integration Reproductive Health and
family planning protected from Human immunodeficiency virus (targeting youth in particular), increased use
of socio-economic and demographic information reliable for preparation, management, monitoring and
evaluation of national strategies and programs, decentralized and region development implement the Action
Plan for Madagascar and the World Health Organization, the favorable legal and socio-cultural environment
for the empowerment of women. The program also includes an important humanitarian aspect to deal with
multiple natural disasters which Madagascar is confronted repeatedly: drought in the south, cyclones and
floods, etc.

§5.1 Cooperation between department management and the United
Nations Population Fund
The United Nations Population Fund has also been selected to implement a Government project
funded by the African Development Bank, in 8 regions of the country the drinking water supply project and
rural sanitation. For this, but also to accompany the draft government decentralization, United Nations
Population Fund has opened two sub-offices covering the northern regions respectively south and posted
operational teams consisting of a doctor, an administrative and financial assistant and a driver in the 8 regions
of the project. Since early 2009, Madagascar is going through a political crisis caused by a change in nonconstitutional regime and the advent of a power unrecognized by the international community, leading to the
suspension of much international aid that the country benefited. The negative effects of the crisis continue to
be felt on the economy, on the living conditions of the Malagasy population and public spending, especially in
social sectors. Thus the state has reduced by 30% the health sector budget for 2010 compared to 2008.
Similarly, a report by the Ministry of Health, 214 health centers were closed in 2011 further jeopardizing the
population's access to health care, especially in remote areas of the country This context has also led to the
abandonment of a major activity included in the action plan of the country program United Nations Population
Fund in Madagascar: General Census of Population and Housing Following non-recognition of the transitional
authorities by the international community, the United Nations System has adopted the implementation
modality of its programs called "special development situation" which prohibits work directly with the level of

political authorities Minister, Premier and President. It became also an urgent need to revisit the United
Nations for Development Assistance Framework to adapt the response of the one System to the new situation
marked by the questioning of the Action Plan for Madagascar by the new authorities and the emergence of new
priority areas (fight against insecurity, respect human rights, political dialogue, peace building, and conflict
prevention). The United Nations System has developed a strategic vision for the period 2010-2011, setting out
priorities for assistance from the United Nations System in Madagascar taking into account the new context of
intervention. This strategic vision should allow agencies to perform their respective mandates in a context of
crisis and transition. United Nations Population Fund has continued to support the country, but by adopting the
modality of "direct payment" next modality for the activities carried out by government implementing partners
and maintaining the pre-crisis procedures with the implementation partners’ non-state work.

§5.2 Evaluation an Interim of Program Country
At the end of the period covered by the United Nations for Development Assistance Framework
(2010-2011) and strategic vision (2010-2011), and pending the return to a normal situation to develop the new
United Nations for Development Assistance Framework, the United Nations System has developed an interim
Program country Assistance covering the period 2012- 2013. This new program builds the results achieved in
the previous United Nations for Development Assistance Framework and translated into action axis
orientations of the strategic vision while incorporating the recommendations of the "Peace and Conflict impact
Assessment”. The main thrusts of the interim program are: supporting the transition process and reconciliation,
the rule of law and the promotion of culture of peace; protection of vulnerable and at-risk populations,
including disaster management; access to basic social services in the areas of education, health, water and
sanitation; support to the economy and strengthening the information, monitoring or evaluation and
communication. Regarding United Nations Population Fund Madagascar, an interim development framework
has been finalized to align the Business Plan and the Interim Strategic Plan 2012- 2013 adopted at
headquarters, as well as the development results framework of the regional office Africa, while conforming to
the interim program of United Nations System. Thus the sixth United Nations Population Fund program
Madagascar began in 2008 expanded to 2013. During the implementation of the program, the United Nations
Population Fund office in Madagascar has worked with 14 implementing partners for the three components of
the program (reproductive health, population and development, gender) at national and regional level see
Annex I: list of implementing partners). The national coverage of the program was for the components Gender
and Population and Development and some aspects of reproductive health: Contraceptive Security, capacity
building in the provision of services Reproductive Health and family planning, Information, education and
communication and National Bureau of risk management and disaster, advocacy, resource mobilization and
development of guides and standards Reproductive Health and Familial Planning. For other aspects of the SR,
it was expected to have at the beginning of 12 concentration of Regions program to provide a complete
package of services and family planning. Since 2010, following a strategic reorientation, the initiative "Quick
Wins" was launched taking into account the health situation in the country. This initiative was to intensify
efforts in the areas where the state of reproductive health is the most problematic, with a view to get more
results. . Targeted vulnerable regions for this intervention have been identified thanks to the availability of data
on the Reproductive Health from the Demographic and Health Survey. The result of a national survey of health
facilities on Obstetrical and Neonatal Emergency conducted in 2008 by the methods is based. Thus, 6 regions
have been identified, the list is attached. In terms of monitoring and evaluation, annual reviews were conducted
during the implementation of the program to adjust and / or redirect future interventions. The implementing
partners have reported on the results obtained through monitoring and evaluation tools (standard progress
report, Annual Work Plan Action Plan of the country tracker, tracker Action Plan of the country program, and
monitoring reports on the ground). Since 2011, a quarterly review of the program was introduced to enhance
communication between United Nations Population Fund and its partners and also to better understand the

issues and constraints to implementation. Furthermore, studies, surveys and specific evaluations were
conducted to draw lessons in order to adjust future planning.

§ 5.3 Objectives and Scope of the Evaluation
The objectives of the evaluation are provided to United Nations Population Fund, the program
stakeholders and the general public an independent assessment of the relevance and performance of the
cooperation program between the Department of Health and United Nations Population Fund. ; to analyze the
strategic positioning of United Nations Population Fund in the context of national development; to draw key
lessons from this program in order to improve future programs of cooperation between Department
management and United Nations Population Fund. The final evaluation of the 2008-2013 the program will
focus on the outcomes and outputs of the three components of the program defined in the Action Plan of the
country program2008- 2011 and the 2012-2013 interim the program. In addition to the assessment of the three
components of the program, the evaluation team will conduct further analysis of the monitoring system and
evaluation of the program.

5.3.1 Questions and Evaluation Criteria
Assessment will be based on a number of issues (evaluation questions) covering the following criteria:
Relevance: How the program objectives they are adapted to the identified national needs? And how the results
of the program he has adapted to changes in the national context?
Effectiveness, How expected results were they or were they about to be achieved?
Efficiency, How the human, financial and administrative resources allocated to the program they have helped
or hindered the contrary production of the observed results?
Durability, To what extent the effects of the activities supported by United Nations Population Fund are they
likely to last after the end of the interventions?
Strategic alignment, To what extent the support provided by United Nations Population Fund to the
partner country he complies with the guidelines of the strategic plan of the Fund: capacity building, support to
disadvantaged and vulnerable groups, support to youth and promoting South cooperation south? To what
extent United Nations Population Fund he fostered coordination and complementarities and avoiding
duplication of activities within the United Nations system in Madagascar?
Responsiveness, how the country office he was able to respond to changes in the context and national needs
(including priorities nationals)?
Added value, How the results observed in the different components of the program could they be
achieved without the support of United Nations Population Fund? It should be noted that the above issues will
be discussed between the evaluation team and the reference group before their final formulation in the startup
phase.

5.3.2 Principles and Methodological Approach of the Evaluation Will Be
Guided By the Following Principles
A participatory approach to ensure the involvement of key stakeholders of the program in the
evaluation exercise; A joint approach closely associating the United Nations Population Fund, representatives
of the national part in a reference group to monitor the progress of the evaluation. The evaluation will proceed
in three phases:
Start-up phase: This phase will include; A literature review; the establishment of a stakeholder mapping
program (stakeholder mapping); Designing a strategy for collecting and analyzing data for the field phase. The
inception phase will conclude with the production of a starting gear.
Field phase: During this phase, the evaluation team collects and analyzes data needed to assess through
interviews and focus groups with stakeholders identified during the startup phase. After the field phase, a
debriefing meeting will allow the present assessment team to the reference group's initial findings and
preliminary recommendations of the evaluation. The final report writing phase: The evaluation team will

prepare a first draft of the evaluation and draft final report of the evaluation report to be submitted to the
reference group (for comments) to the end of September 2012. The comments of the reference group will be
taken into account when reviewing the report by the evaluation team, which then produce the final evaluation
report. It is planned to hold a workshop to present the results of the evaluation to be attended the United
Nations Population Fund office in Madagascar, representatives of the national party and all stakeholders of the
program in preparation for the next program. This workshop will be organized by the Vice Prime Minister for
Economy and Industry, which is the implementation of a coordinating body of the cooperation program
between Department management and United Nations Population Fund.
Table 5-1 Indicative evaluation Calendar

Steps / Product Evaluation

Dates

Writing provisional TOR

March 2012

Advance Mission

April 2012

Finalization of the ToR and recruitment experts

May 2012

Start phase – Submission Inception Report

June 2012

Field phase

July 2012

Drafting of the evaluation report

August 2012

Submission of the assessment report Provisional Final
(the results should help feed preparation the next
program document)

September 2102

- Restitution Seminar

5.3.4 Composition of the assessment team
The team leader (consultant assessment United Nations Population Fund) will assume overall
responsibility for the evaluation process, preparation of terms of reference to production of the final report. He
will lead and coordinate the work of the team and will guarantee the quality of different products the
evaluation. A consultant international provide the evaluation team the necessary expertise in reproductive and
maternal health. The health consultant of reproduction contributes to the writing of the inception report
(characterization of the national context, filtering questions and the evaluation matrix for the health component
of reproduction). It will participate in the work of collecting and analyzing data during the startup phase
(literature) and the field phase (interviews and focus groups). It contributes to the drafting of the final report of
the evaluation (especially the parts relating to the findings, conclusions and recommendations). Given the
specific weight of the Reproductive Health component in the cooperation program, it consultant Reproductive
Health furthermore assist the Team Leader in coordinating the drafting and review activities of the final report.
An international consultant will be responsible for population and development issues and analysis of
monitoring and evaluation program. The consultant will contribute to the drafting of the Inception Report
(characterization of the national context, filtering questions and the evaluation matrix for the population and
development component; formulation of specific questions for system analysis monitoring and evaluation). It
will participate in the work of collecting and analyzing data during the startup phase (literature) and the field
phase (interviews and focus groups). It will contribute to the drafting of the final report of the evaluation
(especially the parts relating to the findings, conclusions and recommendations). A national consultant will be
responsible for the gender component of the program. It will contribute to the drafting of the Inception Report
(characterization of the national context, filtering questions and the evaluation matrix for the kind component).
It will participate in the work of collecting and analyzing data during the startup phase (literature) and the field
phase (interviews and focus groups) it contributes to the drafting of the final report of the evaluation
(especially the parts relating to the findings, conclusions and recommendations). The close links between
genres and program components will lead the Reproductive Health or the consultant responsible the type to
assist or the consultant responsible of the SR in its work. Because of its knowledge of the country, it consultant
national will also play a vital role in the organization (including logistics) and the implementation of the field
phase.

5.3.5 Expected Documents
The evaluation team produce the following documents: An inception report including: mapping-party
stakeholders of the program; the evaluation matrix (including evaluation issues); the description of the
methodological approach for the field mission ; A presentation document (PowerPoint) the main findings and
preliminary recommendations of the evaluation at the end of the field phase ; A draft final evaluation report; A
final report incorporating comments from the reference group .The assembly of documents must be in French.
The executive summary of the report will also be written in English for disseminating evaluation results within
United Nations Population Fund.

5.3.6 Responsibility for managing and monitoring the assessment
The evaluation management will be entrusted to the head of the evaluation team, the Evaluation
Branch of United Nations Population Fund, based in New York. The progress of the evaluation will be
followed by a reference group comprising representatives from the United Nations Population Fund office in
Madagascar, United Nations Population Fund regional office for Africa, services United Nations Population
Fund headquarters concerned by the evaluation and representatives of the national party. It is In-depth study
diploma in social or similar field or medical degree sciences; public health specialization; Knowledge on and
Obstetric Care Neonatal Emergency and Reproductive health of adolescents; Significant experience in
conducting assessments in the area of development for the agencies account or other international
organizations; Experience in the evaluation of humanitarian programs (in emergency situations); Excellent
drafting and communication French and English. International Consultant on Population and Development
(also responsible analysis monitoring and evaluation system of the program):In-depth study diploma in social

sciences or related field; Significant experience in conducting assessments in the area of development for the
agencies account or other international organizations; Good knowledge of monitoring systems and program
evaluation; Good analytical skills and processing of qualitative and quantitative data; Excellent drafting and
communication in French. National Consultant Genre: In-depth study diploma in social sciences or related
field; Experience in the field of gender and gender-based violence; Significant experience in the evaluation of
development projects and programs, and qualitative and quantitative research; Skills in collecting, processing
and analyzing data; Good knowledge of the environment and the functioning of justice in Madagascar;
Reproductive health knowledge would be an asset.

5.3.5 Duration of the contract and conditions of remuneration consultants
Contracts for consultants who will take part in the evaluation will cover the period May to October
2012 and a corresponding number of working days in total:55 days to / the consultant Reproductive Health; 45
days to /consultant Population and development; 40 days to / consultant gender. The payment of consultancy
fees shall be as follows: 20% after validation of the inception report by the reference group; 50% after
validation of the draft final report by the reference group; 30% after validation of the final report by the
reference group. Lutheran Church health department non-governmental organizations (implementation partner
and sub-contractor); development of the Church of Jesus Christ in Madagascar Reproductive Health nongovernmental organizations (implementation partner and sub-contractor);Somontsoy non-governmental
organization (Humanitarian Emergency) non-governmental organization Marie Stops International.

§5.4 Evaluation of activities and materials to maternal health in the
health department
In 2011United Nations Population Fund, equity, has updated the training curriculum in Obstetric Care
and Neonatal Emergency Database, has made the training and health facilities with equipment and introduced
maternal death audits. In 2011 100 basic health centers have been equipped with birthing kits, Manual Vacuum
Aspiration Uterine and vacuum extractors. 8 public hospitals are equipped with kits- laparo caesareans, 11
Hospital Centers Districts 10 Hospital Regional Reference Centers with kit and vacuum extractors. A total of
52,000 individual delivery kits were made available in health facilities to enable them to make free deliveries
at these health centers in intervention areas. Television radio spots were broadcast on free individual birthing
kits and kits caesarean operations and 27 000 copies of the invitation of the woman book to give birth at health
facility level were reproduced (no information is available as to their distribution). Monitoring the use of
birthing kits and individual kits caesarean operations had been carried out at three regions, but the record is not
available. Revision of training module has been adapted and used for the training of midwives and students in
Paramedic Training Institute and training of teachers and tutors on the revised modules. Training materials
were offered for public Paramedical training institutes Direction and Paramedic Training Institute and the
Service safe motherhood.
Production and dissemination of posters protocols for health facilities is Tracing Guide developed
based on international indicators and Supervision Guide and Integrated grid - From the District Health Office:
Base Health Center and The audit of maternal deaths was introduced and followed in hospitals (University
Hospital Mahajanga, Toamasina, Fianarantsoa, regional hospital Toliara, Ambositra Fénérive East, hospital
district center II Itaosy, Moramanga). Epidemiological surveillance of maternal deaths was introduced by the
establishment of sentinel sites in the districts of Toliara II, Fénérive East Moramanga Itaosy, Ambositra. The
order of midwives has been governed by a succession of doctors for 49 years. The presidency is handed in
2012 a midwife who learns to better make visible the profession. The association has recently midwives are to
be part of the "International Confederation of Midwives." It also recently signed a partnership agreement with

the Ministry of Health in order to assert its rights and obligations to prove its mandate to promote professional
wife.

§5.5 Development and updating of the texts governing training and
midwifery to refocus on improving maternal and newborn health
The obstetric surgery Training of general practitioners and nurse anesthetist under the scaling of
management capabilities as a human resource allocation plan public sector. In order to increase the rate of
delivery by skilled personnel and the rate of cesarean sections, the Ministry of Health has initiated a policy of
free Caesarean operations in all public hospitals with the support of United Nations Population Fund. The
introduction of this initiative has taken several steps, including: development of a protocol for the free
Operation for all pregnant women who needs Operation, specifying the content of the different kits caesarean
operations (8 kits based on 8 scenarios frequent pathologies and a necessary Operation, cost estimates for each
kit, needs assessment for 2008-2012, budgeting, allocation of funds, and advocacy. Since January 2009, United
Nations Population Fund has contributed to the purchase of caesarean operations kits for the satisfaction of
needs. Since the beginning of this initiative, women who needed caesarean operations were made free.
The packaging of the kits caesarean operations is done by Central Purchasing "SALAMA" and the kits
are distributed free of charge to hospitals. As a contingency plan, it has been asked hospitals to form the
caesarean operations kits from general medicine for breach of caesarean operations kits. The inputs used by
hospitals to form the caesarean operations kits in case are replaced after breaking through Central Purchasing.
However, certain challenges have been met with the late submission monthly reports by some health facilities,
disruption of stocks, contents of caesarean operations kits are not suitable in all cases, and difficulty of
ensuring the continuity long-term. The regular United Nations Population Fund funds were used to purchase
equipment, inputs for specific training and to co-finance certain planned interventions with topic. The fund
United Nations Population Fund through its support to the midwives training will help increase the volume of
midwives in the country. However a number of constraints were identified that can be counterproductive. For
example, the Human Resources Department is not able to employ all trained midwives although there had
agreed at the time of the formation on the number of midwives who could be absorbed into the health system;
this because the budget has not been made available by the Ministry of Finance. In addition there is little
coordination between the various departments of the Ministry of Health. For example, the HR department has
established needs midwives who are not estimated on the basis of the evaluation (which is made with the
Direction of the health of the mother and child and reproductive) and the deployment and retention the
midwife is not planned (despite a literature review conducted in 200918) or the Health Reproduction
department wants to form nurses training continues as it does not match the pre selection criteria established by
the Direction of the health of the mother and child and reproductive. In 2011, the operational plan of the
commitment of Madagascar to the United Nations Secretary General's Global Strategy on the Health of
Women and Children was developed in a participatory manner with all stakeholders under the leadership
Ministry of Health. The group in Madagascar with United Nations Population Fund leadership provided
technical and financial support to this development. This document provided an opportunity to make a detailed
analysis of the problems hindering the achievement of World Health Organization to Madagascar and was
adopted by all as a reference document for all future interventions in the field of maternal, newborn and child.
At the regional level "quick wins" (which is the subject of increased attention regarding support to SR service
package in 2010) indicators are slightly growing (see diagrams below) especially in the regions of Sofia and
Androy. The data show an increasing trend of these indicators. Regarding deliveries in health facilities
enhancement affect people living in a radius of 8 10 km training. People living in remote areas have a much
more limited access.

§5.6 Rate of Births at Health Facility Level as a Percentage of the
Estimated Number of Total Delivery
Extending thematic fund for maternal health services is planned as part of the operationalization of
thematic fund for maternal health plan. United Nations Population Fund has contributed to the staff training
and equipment of structures. When assessing the health facilities visited had received equipment such as kits or
caesarean operations birthing kit. In the facilities visited provision is coincided equipment with staff training in
thematic fund for maternal health. They were able to practice the training they received. Among midwives
encountered in reference structures at least one had received the training thematic fund for maternal health.
6
5
4

4.5

4.3
3.5

3

Androy
Anosy

2.5

2

Atsimo Andrefana

1
0

2010

2011

2013

2014

Figure 5-1 Rate of births at health facility level as a percentage of the estimated number of total delivery
In some structures (hospital district center gold Basic Health Centre) health workers had been trained
in thematic fund for maternal health but do not know how to use certain pieces of equipment delivered. For
example, oxygen concentrators and are Ambus were still in their Packing. The Ambus for newborn and suction
probes were not available despite the fact that training providers also addresses the resuscitation of the
newborn. Some structures (including references structures Thematic fund for maternal health) do not have
essential equipment (eg reference to Thematic fund for maternal health Ansuhihi does not have a table correct
delivery); The movement of materials between the PhaGDis and basic health center depends on the basic
health center staff (which is sometimes more than 100 km distant); The frequent mutation of trainees
(especially) during the 2009 training wave does not maintain staff in their position (power of decision imitated
in the region). There is no basic personnel data and their training;If most experienced providers practice,
partogram use is far from systematic by lack of records or lack of 'time’; The monitoring mechanisms
Thematic fund for maternal health plan is not clear; Lack of collaboration with communities to establish
transport systems or to motivate women to give birth in health facilities; Some maternal health inputs are not
available at the Basic Health Centre.; There was oxytocin in all facilities visited. But not always for free (by
origin) by cons there was no magnesium sulphate. Motherhood Marie Stops Madagascar Tulear issued free of
charge to the most disadvantaged women, service Safe Motherhood as pre-natal care, ultrasounds, analysis and
childbirth (vaginal and caesarean operations). This action responds to the needs of vulnerable populations, but
remains ad hoc, and creates expectations which health services cannot répondre19. Third party payment: In
2008 and 2009 United Nations Population Fund contributed to the implementation of the third-party payment
system in the South zone East of Madagascar (Universal support base for obstetric and neonatal care and
emergency) by pressing the taken care of obstetric and neonatal emergencies by third-party payment system.
Many Malagasy women benefice free delivery through this initiative. However the figures are not available
routinely. Moreover, the scaling third-party payment system was not possible due to lack of resources financial

§5.7 Activities of Health Management Decentralized
In 2010 United Nations Population Fund in collaboration with department health supported the
detection and prevention of cervical cancer in at level 5 districts in 5 regions with the introduction of 35 testing
centers including cryotherapy centers, the training of 85 health workers trained in screening and 200
community workers trained to educate. Between 2011and 2014screenings were conducted with 7,600 women.
Precancerous lesions were detected with 8% of women examined and cryotherapy conducted with 49% of
them.

5.7.1 Obstetric Fistula
United Nations Population Fund collaborated with the Ministry of Health in the detection, treatment
and rehabilitation of women suffering from obstetric fistula. In 2008, the country office has initiated the
integration load of ten fistulas at 2 faith-based hospitals and also makes a film for advocacy. The results were
very encouraging as 90% of cases were completely repaired. In 2009, 10 doctors (6public and private 4) were
trained in obstetric fistula repair surgery, and thereafter, 29 fistulas were repaired with support from United
Nations Population Fund in 2009.The number of treatment centers is 6 in 2010 and the number of women
treated and benefiting from reintegration is 100 in 2010. 21. The campaign has training surgeons (3 surgeons
from the hospital) and midwives (theoretical and practice). United Nations Population Fund supported the
campaign: rehabilitation of maternity and emergency service; rehabilitation also the operating room, but it is
not operational (the quote did not provide water supply), supply of materials and consumables (delivery kits
and kits caesarean operations sometimes small equipment was missing). Multi-Sector Information Service took
care of recruitment of women with fistula took care of the accommodation. During the fistula campaign,
2international experts attended the hospital's surgeons; brought their "boxes to fistulas" (hardware "repair")
then left with their boxes. United Nations Population Fund had promised boxes: to date they have still not been
fournies.22 No either block to operate e "soda straws" that arise can be taken in-charge if the block emergency
is available. In May 2012 a joint mission between United Nations Population Fund consultant and the
management of the health of the mother and Children (Health Ministry) was organized to track campaign
results. An evaluation carried out in August 2011, observed that the campaign has successfully treat 66 or
63.46% of tools treated. Repairs to the number 15 are only partially successful is 14.42%. We recorded 23
cases of treatment failures is 22.11% • the first 30-day national campaign to eradicate obstetric fistula allowed
awareness the vulnerable population (approximately 4 million women of childbearing age), the training of 14
doctors in surgery Restorative for fistula obstetric, and development of a documentary film on the campaign. •
In 2011 United Nations Population Fund has funded the development of the national strategy to eradicate
obstetric fistula has been validated.

5.7.2 Family Planning
Since 2009, the Global Program to improve the security of supply of reproductive health
commodities) supported most of the activities undertaken by the Ministry of Health in the area of General
Census of Population and Housing, including support and supervision of the routine activities of the
departments involved in this area. Due to financial constraints due to the current political situation, the
Ministry of Health has no budget to finance its operations and is based largely (except for base salaries and
operating costs) on support United Nations Population Fund. In fact, the running costs of ministries Ministry of
Health dealing are provided by United Nations Population Fund through direct payment of all activities. The
global program has made significant contributions in providing products Family Planning (the only
contraceptives available in the public sector are those provided by United Nations Population Fund and
capacity building, with most Part of the funds of the global program spent on products. The products supplied
by the global program are essentially contraceptives, including oral contraceptives (22% of the total value),
injectables (50% of the value total), implants (27% of the total value), condoms (less than 1% of the total
value) and some Intrauterine device s (only 0.1% of the total value). Capacity building has included work on

department and strengthening of the system National Procurement .United Nations Population Fund support
regarding family planning was intensified by the introduction of the global program in 2008 and has led to
different levels of interventions; supporting the development of the 'Strategic Plan for Health Products to
Secure Reproduction in 2008-2012';supporting the logistics system through support to the Director of
Pharmacy, Laboratory and Medicine Traditional and the purchase SALAMA Central as part of Action for the
Integration of inputs Program Health which aims to strengthen the supply system and integrate all health
inputs; Different textbooks have been developed: a manual for quantifying health input requirements that was
used as reference document when quantification sessions; logistics management manual for the district level
and a another for health facilities (translated into Malagasy); a supervisory guide; support for advances in
family planning strategies with among others the development of the (Guidance Guide Organization Strategy
in Advanced Family Planning, 2011 Since 2009, United Nations Population Fund has recruited an
International Advisor Products Securing Reproductive Health and SALAMA logistician to strengthen capacity
in quality human resources. United Nations Population Fund has also supported SALAMA by making
available computers, motorcycles for antennas of Central and planned the staffing car truck to transport Health
inputs in remote areas and equipment for handling. Training sessions have been organized and allow
SALAMA better manage health inputs and quantify the country's needs as health inputs. Other support in
terms of monitoring software package development distribution of inputs is ongoing. In 2008 the product
logistics software health reproduction, Channel, was introduced for the management of health inputs. Channel
has was implemented at the district level, in 2009: "The year 2009 saw the scaling using Channel and
strengthening the logistics system of health reproduction products through strengthening capacity of health
personnel 22 regions and 111 districts, the provision of computer equipment and the supply of health
reproduction commodities.

5.7.3 Challenges in the implementation
Importing data by district Channel central level; Involvement of regional directors and district chiefs
doctors in the use and monitoring the levels Channel decentralized; • frequent mobility of staff involved in the
implementation of the strategic plan does not allow health reproduction ownership of planned interventions;
No feature logistical committees health reproduction family planning in place, especially at decentralized
levels; Absence of a plan for monitoring or supervision for monitoring integrated logistics management of
health products reproduction. To which must be added frequent breakdowns of computers (due to terms of use
and users). of the Affirmative action has been implemented, an agreement (in 2010) with the Operation and
Maintenance Service of Ministry of Health (material assistance and maintenance) and "training on using the
software for Channel Inspectors doctors, health reproduction-makers and regional health directors to improve
the quality of reporting in health reproduction and especially avoid breaking health reproduction inputs and
stocks in health facilities " The service operation and computer maintenance within the Department of
information systems estimated that 25% of computer equipment is functional in 2012. This is consistent with
the situation identified during the field mission at sub-offices Tulear and Sofia 2 of 9 districts have a computer
station dedicated to functional Channel in the health region Tulear; Channel the position at the Public Health
Regional Directorate Sofia down for months. This is linked to the health planning• the fragility of the material
(relatively low end), including inverters, especially compared to the poor quality of electricity; error-handling
users (lack of initial training); the conditions of use (local undeveloped); the lack of antivirus. The most
common hardware failures relate motherboards (accelerated oxidation of the coastline to the east), the block
supply and fans (west). The software faults are many, related to the absence of virus that then jobs are not
secure. The maintenance system has been set up within the Department of information systems but has very
insufficient means to fulfill its mission and in particular to maintain the 111 posts delivered in 2010 to district
health services funding from United Nations Population Fund.
The Service Operation and Maintenance of Computing have established a visit schedule, and on-site
have been implemented only half of planned missions (and deemed necessary for the new hardware). In
principle, Mission per quarter would be required; Only 2 per year was achieved in 2010 and 2011 (no until
mid-2012). This Mission deficit is related to both the slow procedures for United Nations Population Fund

launched the missions and the low level of motivation agents with missionaries compensation ($ 18 / day) and
mission expenses deemed too low (not indexed). The cover 75% of the districts covered by a servicing mission
does not imply that 75% of jobs are functional: they are likely to fall back down very quickly since the
conditions of use are unchanged. In some cases, the services themselves bring the items down to the central
service for repair during missions to the capital. The reporting rate Channel is estimated at 15-20% by
Department of information systems (confirmed by field mission in Tulear where Channel functional in only 2
of 9 districts), which removes much of its usefulness to the device. The difficulties identified in 2009 have
largely lost and brought extra work (input and validation) at the district level. The park of computers solely for
Channel lack of maintenance, the service does not have the financial resources to do more 2 missions per year
in the field. Specific data on whether the Channel is functional throughout the country are not available.
Estimation of Decentralized technical services is that 75% of the park is not functional to varying degrees
(confirmed during field missions in Tulear and Antsohihy)
Table 5-2 districts quick wins it is reported that Channel is functional in 70% of districts
Androy

Anosy

Atsimo
Atsinana

Atsimo andrefana

Distric Number

4

3

9

5

Number
of
structures
whichthe staff was formed
in EmONC (CEmONC /
BEmONC)

9

7

58

7

Number
of
structures
received
EmONC
equipment(CEmONC
/
BEmONC)

9

16

59

7

3

12

2

Number of structures who
benefited
from
the
presence of a midwife
contractual (UNFPA)

However, these data are compiled by the Supporting doctors and support who do not have access to
districts and the information gathered during the visit regions during the evaluation does not always correspond
to the information compiled below. Use machinery, or do not have the time to data entry. Sometimes the
person is not formed one that is supposed to use the software. The power cuts in some areas and lack of access
are internet other limiting factors. The reports are usually very late. It was reported that orders are made
manually. The tracking device and programming United Nations Population Fund makes no mention of these
problems since 2009. The mid-term evaluation of the program noted that global Channel is still at a stage of
development in terms use and improvement of tools, and has not had until now of clear impact on the
management of inputs, including health reproduction inputs. Only 50% to 60% of potential users of the
Channel are a strategic realignment was arrested in June 2012 which has improved Channel software features
(on tender of the Directorate of the Information System), reorganization and especially the institutionalization
of the device by decree and memos. It is expected that the results especially at Channel are taken into account
in the annual evaluation of medical inspectors and regional directors which clearly identifies retrospectively

responsibilities. Annuelles33 of evaluations were conducted regarding the security of health inputs. These
assessments do not to compare results from one year to another because they used different methodologies.
In 2009 the leading cause of advanced stock outs by the managers of service delivery points was stock
outs at the PhaGDis. IN 2011, the lack of trained personnel to the PF service offering (mainly Intrauterine
device and implant), non PhaGDis honored by the command and control are not carried out the main reasons
for not availability out of stock and FP products in health facilities. - It has been observed stock outs of stock
in the south that are the result of supply difficulties at the central level (SALAMA was not delivered) and
collection difficulties in transport costs (District health have difficulties meeting their commitments
SALAMA). During the United Nations Population Fund program has supported the development of tools to
strengthen the training of health workers in Intrauterine device insertion and community health workers in
health reproduction; Course book for participants: family planning contraceptive Intrauterine device training
with various modules including counseling (2011); Trainer's Manual: family planning contraceptive
Intrauterine device training with various modules including counseling (2011). Reference: family planning
training Intrauterine device contraception with various modules including counseling (2011); Practical guide
integrated family planning for health workers (2012); Guide for the reproductive health service for health
workers in community. United Nations Population Fund aims to expand the supply of long-term methods
emplaning particularly in intervention districts. The number of health workers trained in Intrauterine device
and emplaning per district varies from region to region and the number of new sites offering emplaning. The
PF of services has increased with improved contraceptive supply, diversification of supply with the
introduction of Implanon and long-term methods (minilap and vasectomy) proposed during advanced strategy
poor implementation by different partners such as Marie Stopes Madagascar. Strategy services advanced
minsitry provides their services to the poor in 160 towns (regions Atsimo Andrefana, Anosy, Androy,
Vatovavy Fitovinany, Atsimo Atsinanana, Sofia and Betsiboka) aim at offering services family planning
outreach, in particular for disadvantaged and vulnerable. The customers receive free family planning methods
in Long Term and permanent, is also conducted monitoring women pregnant through antenatal care Free.
An orientation guide on outreach organization for family planning has been developed with service district in
2011 detailing the steps:
Step 1: Orientation officials regions and district on the organization of outreach using the guide
(Team Public Health Service District and Team Regional Directorate of Public Health)
Step 2: Orientation community workers and organizing activities;
Step 3: Awareness Fokontany leaders on holding outreach sessions and strong with messages locally adapted
easy.
Step 4: Session provides family planning services
Advanced Strategy The program has helped contribute to the increase in contraceptive coverage in
areas of intervention. "The objectives depend on the method; the Intrauterine device and tubal ligation are
down especially in certain regions such as Androy. While the implant, despite a short break period, exceeded
the planned objectives. The achievement of objectives depends on the method, the Intrauterine device and
tubal ligation are down (compared to the previous year) mainly in certain regions such as Androy. While the
implant, despite a short break period, exceeded the planned objectives. ".

§5.8 Advanced Strategies Result Marie Stops Madagascar
This strategy helps the development of Partnership Public; Private (reporting program and supply
level health facilities) and with the other programs (Collaboration with Health Net II35 refer to women).
However coverage of advanced strategies is difficult to assess and shortcomings were noted such as
cooperation with basic center health which do not always provide monitoring and customer support, or
sometimes teams travel for just a minilap intervention, which is not cost efficient."Total Marketing Initiative"

project started in 2010 by a study funded by Program for Appropriate Technology in Health, Reproductive
Health Supplies Coalition and Marie Stops International in several African countries. It was implemented by
Marie Stops Madagascar and United Nations Population Fund country office with support from Futures Group.
The study will inform the development of an approach 'total market' which aims to enhance the role of the
private sector in the distribution of contraceptives and provides planning services.
The study "to analyze the evolution of the policy of family planning in Madagascar, analyze equity in
family planning and market segmentation contraceptives from the document of Regional Health Directorate
2010-2011, to demonstrate the importance of the contribution of the private sector in the market for
contraceptives, to highlight public-private partnership and to highlight best practices in planning ".Free family
planning services (established in 2011) has certainly improved the rate of contraceptive use as demonstrated by
the evolution of the demand for family planning in the public sector between 2010 and 2013. However an
analysis of the status conducted in 2013 recognized the importance of focusing on the expansion of long-term
or permanent methods. A quarter of married women would like to limit or stop childbearing. Yet almost all
these women use temporary methods is placing a heavy burden over it determination and the health system for
their replenishment or resort to less effective traditional methods is placing at risk of unwanted pregnancy.
During the group discussions it appeared that many problems are related to business counseling health workers
providing family planning services, Side effects are a major reason for discontinuation of contraception. It also
appeared that the decision; making power is not between women's hands and despite their desire to use family
planning methods they dare not because of the fear of their husbands and often cannot use family planning
without the consent of their family (father, husband, and stepmother). This is confirmed by a large gap in the
ideal number of children preferred by men and women. Finally the desire of large families is very present
among the women interviewed. A significant barrier to the use of FP is that women perceive negative
community attitudes. Some women cannot obtain the necessary rest after a Minilap action because they have to
support their families.

5.8.1 Sensitization
Information, education and communication materials for health reproduction awareness activities have
been produced with the support of United Nations Population Fund comics, posters, wall panels, pocket
calendars, shirts, bags and caps bob. Awareness activities on health reproduction services and human immune
virus and family planning were conducted during different campaigns, at different socio-cultural events, day or
week of health and through the health reproduction broadcasts messages at the audio-visual: radio stations and
the national television and regional Regarding the support to demand, 200 community partners were trained in
Safe Motherhood and 30 traditional midwives and 230 community facilitators (public, private) are formed and
Information, education and communication in 2009;In order to reach rural populations, 190 health workers and
988 community workers have been trained to raise community awareness on the use of reproductive health
services in six low-performing regions 2010.The Mobile Video Units has been used to organize
communication sessions for behavior change for rural populations and those living in remote areas. Also a
documentary on obstetric referrals, births attended by trained personnel and many spots on Motherhood. Risk
(institutional delivery) and Family Planning (harm many children, free contraceptives) were performed. It is
particularly difficult to assess the results of these interventions since little information is available about the
strategies adopted, the selection of target groups and the process of defining messages in the visuals that were
produced with the United Nations Population Fund support for animation or supported by United Nations
Population Fund. In addition data on the coverage of these activities are not available and no assessment of the
impact of awareness activities has been conducted. Despite awareness of family planning, large gaps remain in
the knowledge of family planning. About 20% of women cannot name one modern method of family planning.
Communication campaigns do not specifically target population groups with low levels of knowledge about
family planning and sexual and reproductive health in general. The messages must be focused on marginalized
populations, such as men and illiterate women, adolescents and the rural poor.

5.8.2 Advocacy
In 2008 the Reproductive health of adolescents has been proposed in the general policy of the State
Ministry of Health. The review of the National Youth and Adolescent Health Policy and Strategic Plan
Development for Reproductive health of adolescents was planned in 2011 took place in 2015. A consensus
meeting of all stakeholders on Reproductive health of adolescents was organized in Antananarivo to determine
the packages of activities Reproductive health of adolescents and roles of each actor with the support of United
Nations Population Fund; The country office of United Nations Population Fund was actively involved in the
process of drafting the new National Strategic Plan of the lute against protected from Human
immunodeficiency virus by hiring a national consultant and participating in various technical meetings to
prepare and to strengthen the integration of adolescents and young people and key populations at higher risk in
the new Plan and especially strengthen the protected from Human immunodeficiency virus and SR integration;
The ministerial decree under the Law on the National Youth Policy formalizes the "Interministerial Committee
for Youth," which brings together several government bodies working in the areas of youth and involved in
issues related to youth. The African Youth Charter was ratified in Madagascar. The partners have recognized
the leadership role of United Nations Population Fund for the reproductive health of adolescents and youth
promotion of rights in general
Youth representatives from Madagascar were able to participate in the International Youth Conference
in New York and International Conference on Decentralized technical services protected from Human
immunodeficiency virus in Addis Ababa; Youth representatives participated in the drafting process of the
national strategic plan for the fight against health deficient acquit; Young people are part of the 'task force'
which coordinates regional youth-related activities in the locality. As the country office supported the
participation young to the General Assembly in Burkina Faso, participation in the youth forum on the sidelines
of Institute in Madagascar No- organization governmental is United Nations Population Fund partners
organized pleas from some religious leaders and school directors for the Reproductive health of adolescents’
service integration in medico-social activities. Participation in the partner network for health reproduction and
Human immunodeficiency virus integration; Task force for the promotion of youth Life skills; Network of
partners involved in the Reproductive health of adolescents and protected from Human immunodeficiency
virus and promoting behavior change for health reproduction and family planning and protected from Human
immunodeficiency virus. "The joint program of the fight against protected from Human immunodeficiency
virus especially in the field of prevention co-led by United Nations Population Fund and United Nations
Children's Fund strengthened the youth development intervention coverage and this collaboration has
strengthened the complementarily with other stakeholders in the field Reproductive health of adolescents and
1protected from Human immunodeficiency virus ".In 2011, doctors support the regions and the expert in
monitoring and evaluation available to the Executive Secretariat of the National fight against protected from
Human immunodeficiency virus Committee supported the regions in the development of integrated regional
plan the fight against protected from Human immunodeficiency virus.

5.8.3 Integration of Reproductive health of adolescents services in voluntary
testing centers and other existing health
An integrated training curriculum Reproductive health of adolescents or family planning and protected
from Human immunodeficiency virus or Sexual Transmissible Infection was developed and implemented in
2011. An integrated training Reproductive health of adolescents, family planning, Sexual Transmissible
Infection counseling and testing was provided to providers of both regions complementary training on
counseling for key groups at high risk; In 2012 several partners (including United Nations Population Fund
was the leader) have been involved in the operationalization of the concept of "service of the young friend"
through the implementation of youth-friendly health center. The document on the concept "youth friendly
clinic" was validated by the interministerial committee. The valid document allowed having a standards and
standard reference document for all stakeholders that will be involved in the health and development of young;
in health of adolescent reproductive a very limited number of health workers were trained in youth-friendly

services health workers in three regions quick wins). United Nations Population Fund supported the
Reproductive health of adolescents and clinical Malagasy Association for Family Welfare however Lutheran
Church health department. The necessary equipment was not supplied (including condoms and Information,
education and communication materials) and health reproduction services could not be offered. Some reports
mention the increased attendance but data to support this finding. One factor is the use of reference cards by
young peer educators. "The results of this are palpable to the extent that young people come to the centers
equipped with these cards to request services"; Continuous providing clinical services in counseling, diagnosis
and management of Third-party payment system with protected from Human immunodeficiency virus
screening at the point of Youth in the intervention sites were organized in 22 youth-friendly health centers
including 12 centers are private clinics and 10 public health facilities; Data on the number of youth referred to
health facilities 'youth-friendly' is not available systematically. "The collection of data on the impact of
training providers was not conducted. The program is unable to measure the use of these existing structures.
"One some data are available and cover new young users familial planning youth diagnosed Third-party
payment system, Third-party payment system cases treated young, youth diagnosed with protected from
Human immunodeficiency virus. Strengthening capacities in the field of life skills (skills to everyday life)
including income generating activities ; in 2011, 340 young peer educators were trained in the Reproductive
health of adolescents and life skills to boost demand health reproduction services; songs of struggle against
protected from Human immunodeficiency virus (varieties and folk songs) were composed and agencies
Implementing used for cultural events in the locality to convey the messages of the fight against
spread of Third-party payment system and protected from Human immunodeficiency virus for the supply of
services, providers of basic health centers in regional offices Health Analamanga and Vakinanakaratra
received training in integrated Reproductive health of adolescents, Third-party payment system counseling and
protected from Human immunodeficiency virus testing. Two young Properties also offer voluntary testing
centers in protected from Human immunodeficiency virus and, in each center there is a medical provider who
works there every day to welcome young. United Nations Population Fund supports youth centers through the
Ministry of Youth, health organization, Lutheran Church health department and Malagasy Association for
Family Welfare. Support seen at evaluation results in leisure facilities (keyboard, foosball, board games,
balloons ...) and sometimes hardware Information Education Communication. Talks on health reproduction are
organized in these youth centers. The Ministry of Youth considered United Nations Population Fund has
greatly helped to revitalize the Reproductive health of adolescents. During field visits it was found that the
quality of the animation varies according to the people present and their technical competence and animation
(sometimes they are providers health or teachers).The training of peer educators Young is implemented by the
Ministry of Health, Youth, organization helath, and Malagasy Association for Family Welfare Lutheran
Church health department (between 25 and 65 per region in 5 regions quick wins). The peer educators are
supposed to do home visits to disseminate information messages to their peers. Yet very little monitoring is
done (except by certain no organization governmental) no information is available yet on the percentage of
assets service after training at the central level (A Androy were still active on visited 50 formed in the center)
and the quality of the messages disseminated to those who led outreach activities. The their technical
competence and animation (sometimes they are providers health or teachers)

5.8.4 Malagasy Association for Family Welfare
The training of peer educators Young intervenes only in urban areas and mainly affects young people
in school. "We do not touch the majority of young people; majority of unwanted pregnancies concern the rural
areas” Few strategies were defined in order to reach young people not attending school (except by Malagasy
Association for Family Welfare). No information available regarding the exact coverage of these actions. No
parent / religious leaders were trained in Reproductive Health quick wins in areas but a 2010 report mentions
between 300 and 500 leaders and peer educators have been trained by the Ministry of Health, Youth, health
organization, and department health without information about the rental and targeting of these activities. In
2010 the curriculum life skills (civisms Peace and Environment) has been harmonized in cooperation with
United Nations Children's Fund. 30 trainers trained in 2011 enabled the training of 155 services and training

in life skills and Standard progress report to teachers) The training of peer educators Young Anosy regions and
Atsimo Andrefana, in partnership with the Lutheran Church health department, Regional Directorate of Youth
and Recreation Promotion of behavior change in Reproductive Health and planning familial and protected
from Human immunodeficiency virus
In 2011 the response of the fight against protected from Human immunodeficiency virus has begun to
be decentralized. The actions that were undertaken were held in regions across the health service providers,
youth peer educators and no governmental organization and under the supervision of physicians support to
regions. The office supported the holding of the celebration of World Day against protected from Human
immunodeficiency virus interventions in 8 regions in partnership with the regional coordination units in the
fight against protected from Human immunodeficiency virus and regional health directorates. Awareness
sessions and conferences and debate on youth and protected from Human immunodeficiency virus with a focus
on reproductive health and dual protection on family planning methods and protected from Human
immunodeficiency virus screening were held were held. Awareness and regional officials responsible for
municipal councils on the links between early pregnancy and sexual health problems of young people has had
some results with several cities that have shown their commitment by giving and landscaping spaces for youth.
Outreach activities were conducted on the topics of early pregnancy and services protected from Human
immunodeficiency virus mainly during punctual socio cultural events: Celebration of World Day against
protected from Human immunodeficiency virus, celebration 110th anniversary of evangelization and social
action of the archdiocese north, national meetings of school sport .This outreach activities include the
distribution of bandanas, key chains, pens and fanny packs and flyers. "The organization of a campaign on the
vulnerability of adolescents to early and unwanted pregnancies in 3 towns helped rally the various stakeholders
at the decentralized level and to have their emphasis on engagement with traditional leaders. The success of the
campaign shows that young people are able to carry out important activities to raise Reproductive Health
demand service.”Awareness activities are sporadic without being part of a global strategy and are not always
accompanied by distributions of promotional objects and visual aids are not always available. United Nations
Population Fund through the activities implemented by the implementing agencies has strengthened the
demand creation and access Youth protected from Human immunodeficiency virus screening. "We used
festivals, socio-cultural events and sporting events to convey messages and to provide public counseling and
testing services. The campaign on condom use among young people and the general population was conducted.
United Nations Population Fund has supported the implementation of the campaign on the SRA in schools
Awareness activities for creating demand for Reproductive health of adolescents has also seen a remarkable
development. Promoting youth participation in development programs through the operationalization of youth
councils United Nations Population Fund has supported a number of activities to stimulate youth participation
as follows: Youth development advocacy so they can plead their cases during the preparation of local
development plans. United Nations Population Fund has set up in 14 towns of community youth networks, a
discussion platform for youth issues in the community; Information education communication materials to
fight against early pregnancy and to youth awareness and the general population on the rights health
reproduction were developed. A pilot program for the development of income-generating activities by
attacking the economic determinants of health behavior of young people was undertaken in favor of 20
underprivileged youth in a region. United Nations Population Fund supported the evaluation of the pilot phase.

5.8.5 Position of the Reproductive health of adolescents
Many activities were carried out at the beginning of the sixth program for Reproductive health of
adolescents, but the activities are reduced during the period including following the change of name of the
department to which the youth issue was not a priority. Some activities do not fall within the strategies of Cell
planning and monitoring and evaluation; such support has a local no governmental organization protected from
Human immunodeficiency virus to group women with Human immunodeficiency virus positive or living with
a husband to discuss their concerns. The position of the Reproductive Health has changed at the country office
in 2011. This was motivated by the lack of ownership by the Ministry of Youth. The change in 2012 is a
transversal approach or young problematic is seen as a global problem. The directions of United Nations

Population Fund globally were considered. The funds allocated to the Ministry of Youth in 2012 tripled (650
000 USD) and service are signed for the 3 components (gender, health reproduction, Population and
development). United Nations Children's Fund is very active regarding youth: peer educators training module
was developed together; United Nations Population Fund continues to finance part of the implementation to
ensure that the question Reproductive Health is not lost along the way.

5.8.6 Strengthening national capacity in the production
The United Nations Population Fund supports the national management of risks and disasters Office,
created in 2010, which ensures coordination of all interventions in the management of risks and disasters and is
under the Ministry of Interior. The collaboration with United Nations Population Fund mainly in strengthening
the statistical management has resulted in depreciation in computer equipment, information management and
financing of wage webmasters. United Nations Population Fund also helped obtain maps and demographic
data. The support was interrupted in 2010 when the political crisis. The breast disasters Office region l groups
meet according to need; United Nations Population Fund is part of region protection group. The ministry group
for monitoring and evaluation receives funding from United Nations Population Fund, among other formations
by a consultant funded by United Nations Population Fund in several regions (in 2010).The main United
Nations Population Fund contribution is the inclusion of Reproductive Health in emergencies as well as the
distribution of kits and awareness of humanitarian actors in health reproduction. In 2010 following the
cyclones and floods, United Nations Population Fund conducted a staffing emergency Reproductive Health
kits (dignity kits, delivery kits, caesarean section kits) in 40 basic health centers and 9 Level II reference
hospitals (laparoscopic caesarean) and training of providers of these health centers with the use of these kits
(which included universal precautions to prevent protected from Human immunodeficiency virus and adequate
care for pregnant and post-partum women with health service. These health facilities were spread over all
sectors affected by disasters by mapping prepared by the National Bureau of Disaster and Risk Management.

5.8.7 Advocacy for the integration of Minimum Initial Service in the national
contingency
A national contingency plan was established in 2010; it is updated each year in the presence of all
stakeholders Stakeholder study committee in service disasters (United Nations Development Assistance
funding) and operation service provides technical support; in 2010 such prioritization in the distribution of kits
was discussed in the case of cyclones with or without floods. The Malagasy Red Cross participates in the
discussions of the national contingency plan through his services (risk managers and disasters).The
Contingency Plan includes health reproduction aspects: among other things the minimum training device
Emergency Minimum Initial Service (initial training was funded by United Nations Population Fund in 2011 in
Cameroon). The plan provides for collaboration with the Ministry of Health, which must cover the
medications, with the exception of delivery kits that are supported by United Nations Population Fund. The
Health Directorate of the mother and child manages the distribution of kits. 30 leaders from 15 regions of
Madagascar, the Malagasy Red Cross Society have received training of trainers in Minimum Initial Service
Package and Information management, monitoring and evaluation in humanitarian situations. A new listening
center and legal advice opened in the Androy region to work in synergy with assistance from component health
reproduction humanitarian emergencies.
In 2010 a training of trainers on the Ministry health was organized to form a pool of trainers at
national level. 25 people from the Ministry of Health, Malagasy Association for Family Welfare, and
Malagasy Red Cross, World health organization were formed. This was followed by the formation of regional
coordinators and 110 districts Minimum Initial Service covering 22 regions of Madagascar (prevention of
maternal and infant mortality in emergencies, coordination of health reproduction; related activities and
prevention of sexual violence).At each region Minimum Initial Service coordinators involved in disaster, they
advocacy; There are at least Minimum Initial Service by district coordinator. However training is a standard
module and is not always adapted to hurricanes and flooding (because it was developed for war situations). As
there are funding problems to deploy Minimum Initial Service coordinator during the cyclone season (January

to March). After the formation of regional coordinators Minimum Initial Service, it was requested that regional
coordinators establish an action plan with a budget; Regional Coordinator sent the plan but there was no result.
In 2011 training for psycho-social care of women victims of rape was funded by United Nations Population
Fund (65 doctors and paramedics in the northern health facilities). There are still gaps to the extent that the
volunteers of the Regional Coordinator are not trained and it is difficult to communicate with rape victims for
referral to FS. There is no proper monitoring and follow-up training is done during an emergency; by coaching.

5.8.8 Development of Partnerships with No Governmental Organizations
United Nations Population Fund is working with the Red Cross in a partnership between the
Department of Health, and United Nations Population Fund established Malagasy Association for Family
Welfare in 2010. United Nations Population Fund support mainly consists in the implementation of the
Ministry health. However in reality the partnership conditions have not always been met because the
implementation of activities has not always been effective, the supporting documents regarding expenditure
were not always appropriate and the expected data have not always provided. United Nations Population Fund
has set a charge of health reproduction and Gender project of hers Regional Coordinator. Also to meet the
recurrent drought plaguing the south, a joint United Nations Population Fund was initiated in 2008. United
Nations Population Fund has made provision of materials and equipment for 4 basic health center and dignity
kits to target women. He supported the training and monitoring of community agents of the 5 targeted
communities to mobilize the population to frequent the health reproduction services. Collaboration with WFP
has allowed a staffing diet of women who use the health reproduction services.
In 2009 a partnership was signed for 4 years between the Principality of Monaco and Andorra for
funding of joint United Nations Population Fund as part of humanitarian crises related to drought in South
Regions (Androy, Anosy, Atsimo Andrefana). Indeed, the rate of food insecurity in several communes of these
regions is very high. The program's objective is thus to reduce the vulnerability of women of childbearing age
by improving access to free health reproduction service and quality; Awareness of the population with 15
municipalities of South Regions 3, distribution kit dignity and hygiene items for women of childbearing age
have used the services of health reproduction free staffing iron folic acid for pregnant women and recent
mothers and lives for the A-partum and food distribution by service health. The members of the local
association Somontsoy were mobilized to supervise community workers and community leaders to make better
use of health reproduction quality services and free response to the humanitarian crisis. The challenges
encountered were the timely availability of necessary resources, accessibility for people living more than 10km
from health centers and storage of individual birthing kits (dignity, hygiene ...) at Commons the ability of
local no governmental organization s and community to react quickly in situations crisis iv) measurement of
results (quantitative and qualitative) in a context of crisis.

§ 5.9 Management Materials delivery and United Nations
Population Fund
In 2010 the common response was very disturbed by the fact that this was the first time that agencies
have tried to make a joint region answer from a common multi-sectored assessment. Since reproductive health
is an integral part of the health cluster the division of labor within the cluster was somewhat disturbed fault
competent human resources. United Nations Population Fund also provides dignity kits, delivery kits,
caesarean section kits. When cyclone Giovanna, United Nations Population Fund conducted regional
distribution of kits. The prepositioning of kits was made SALAMA, but the procedures were very heavy and
extensively discussed among stakeholders: Health, Malagasy Association for Family Welfare, and United
Nations Population Fund but unresolved problems has led to delays decision to United Nations Population
Fund. It took 3 weeks to transport the kits. There have been problems with the expiry date of products; once a
request sent to SALAMA, delivery was made very quickly. Coordination is very low in emergencies. During
the field visit it became clear that interventions are not coordinated with the medical inspector of beneficiary

districts in particular for the distribution of kits. It could also be observed that this distribution if conducted by
no governmental organization can be very random: split kits. It was also noted that the lack of monitoring on
the ground has failed to ensure that these activities are carried out effectively.SALAMA and the direction of
the pharmacy was appropriate Channel. At SALAMA significant support was set up to make the system both
in hardware that training personnel at various levels.
In the regions all the activities promoted by United Nations Population Fund are included in the
regional action plan. However these plans are not always centrally approved. However political instability has
led to changes in officials in the public service as well as health workers. Many people who have been trained
at all levels with the support of United Nations Population Fund are mutated and replaced by people who have
received a similar training. the country is completely dependent on external funding especially since the 2009
crisis and public funding decreases regularly suggests that the government will not be able to take in the
medium term support activities funded by United Nations Population Fund. Actions such as awareness and
communication for behavior change leaves consider no effect on the long term because they are planned ad
hoc basis with no monitoring or assessment seeking to measure the effects of these actions. Government
partners have appropriated developed contingency plans for emergencies. Development into national
development policies have not produced. United Nations Population Fund support to the realization of service
health, both in technical policy dialogue was successfully until the decision in 2011 to withdraw funding in
response to the political crisis of 2008-2009. On the eve of the decision, United Nations Population Fund
activities had been carried out since firstly the amount of available funding ($ 12 million) would have allowed
the realization of the census, and on the other hand, the technical prerequisites (census, 40 computer
workstations in the central cell National Institute of Statistics, printers, photocopiers) were acquired. United
Nations Population Fund has particularly enabled the realization of a pilot census (in the south).In the longer
term, the support provided by United Nations Population Fund through National Institute of Statistics for the
training of technicians, senior technicians and engineers statisticians and demographers has directly tangible
effects on operational capacity building of statistical data . This United Nations Population Fund support is the
most efficient and most sustainable contribution to strengthening the capacity and operating data.

5.9.1 National Institute of Statistics
National Institute of Statistics, with the results in terms of tools and international technical assistance
associated with initial support from United Nations Population Fund, was able to use other sources of funding
(United Nations Children's Fund, United Nations Population Fund) for the periodic survey of households
which notably allows measuring the evolution of poverty at national level. The sector studies as service and the
Survey Periodic household have therefore not suffered from political instability and were carried out and, at
least for the first scattered at central and regional level. The data were made available to policymakers and the
public in 2010 for the National level results. The results of the regional level were finalized in December 2011,
three years after the investigation, indicating a lack of expertise and resources to National Institute of Statistics.
United Nations Population Fund could usefully influence health indicators to obtain more relevant information
on the reproductive health and maternal health. Monitoring data for the implementation of development
programs also vital advocacy for the integration of Population and development approach have not been
produced, at least not in their original sense and quality required. The support of the United Nations Population
Fund to strengthen monitoring device development programs and thus strengthen the scope of national and
region planning has focused on health service, initially in connection with the plan action Madagascar 2006.
Plan action Madagascar had not originally planned system. . United Nations Population Fund advocacy in the
previous cycle has introduced this dimension. The support has been focused with the World Food Programmer
with the provision of a technical assistant and financing of computer equipment at the central level (2010,
2011) and in 6 regional offices in 2011. Financial support has been available for training, development and
distribution of the procedural Manual (December 2010) and the publication of annual and popular pamphlets
reports. The annual reports were published to date from 2008 to 2011, with an increasing delay (weeks to
months), which are symptomatic of the growing difficulties to effectively raise issues of regional platforms.
The regions have been in a position of trying to implement the procedures manual developed by the Vice

Prime Minister in charge of Economy and Industry in 2010 that from National Integrated Monitoring
Evaluation System. 2011, when the service health were finally put in place (in 16 regions out of 22) by order
of the region (the appointment order Centralization and regional analysis cell members is still pending in some
areas). The main content of annual reports Central National Integrated Monitoring Evaluation System until
today comes from data produced by National Institute of Statistics by means of its regional offices, and hence
thereby indirectly attributable to the support of United Nations Population Fund (the National Institute of
Statistics). The training provided by United Nations Population Fund in 2011 has not been implemented up
there and the staff is trained for 2/3 of them longer in office (reassignment). The manual of procedures and
organization of National Integrated Monitoring Evaluation System is not used as a normative reference,
leaving the possibility of adapting to skill level identified among the participants in the regional platform;
aggregation for the regional framework will be less difficult. Region administrative data, programs and no
governmental organization s hardly reach the Centralization and regional analysis cell, usually late and often
regardless of format chosen. Given the accumulated obstacles, tracking database programs and the
implementation of the necessary planning advocacy for the integration of population and development
approach into national development policies will not be produced despite the Direct United Nations Population
Fund support at the central level and indirect support (local support) at sub-offices. . The constraints had been
identified by the annual review 2010, but only the most immediate were integrated into Annual Work Plan
2011: The computer equipment provided by United Nations Population Fund and Centralization and regional
analysis cell has been made available in May 2012; its effect has not yet been felt (it will however be limited
by the lack of access to Internet of Regional Directorate of the economy). Capacity and advocacy means actors
with the integration of population and development approach were not significantly and sustainably
strengthened. United Nations Population Fund support in strengthening the advocacy capacity of actors with
the integration of population and development approach was implemented by the Directorate Planning
methods Vice Prime Minister in charge of Economy and Industry. It benefited from 2010 the support of the
technical assistant previously in support of World Food Programmer (for the establishment of National
Integrated Monitoring Evaluation System). This support lasts until now, but shared (60/40) from 2012 with the
Directorate for Economic Cooperation and External Aid. The awareness on the link and population
development itself was those that met the most problems of implementation, with successive strategic shifts
and, ultimately, the less identifiable effects. Beyond implementing partner, the Method and Planning Branch
within the Vice Prime Minister in charge of Economy and Industry, operators and target beneficiaries were
renewed almost every year: The University Catholic Madagascar, a platform for religious organizations and a
"platform" of journalists, the Malagasy Institute of Planning Techniques without apparent link with previous
activities with little relation to the dimension Population and development. The reasons for these change
strategies are not clearly explained in the Annual Work Plan and explained afterwards. After the postponement
of decentralization, the actions supported by United Nations Population Fund have been redirected local
authorities to state services with planning trainings organized in Antananarivo and panel discussions to
sensitize decision-makers at regional Population and development links. These panel discussions, as Antsohihy
for example, were supported by sub-offices and have been well received in each region, uniqueness the event
reduces their educational and practical impact on the effective implementation of the Population and
development links.

5.9.2 Other Plan Action of Department Management
Action Plan of the country program initially planned regional studies potentially contributing to the
awareness of regional decision makers. This initiative has evolved to studies point of regional scope. : A study
of resilience after natural disasters (in 2 parts, made by sexually transmitted infection in 2011, edited), a study
on the consequences in health reproduction Sunday prom youth (conducted by the University of Antananarivo)
and a study on access to basic social services. There was no operation to date and dissemination of these
studies therefore remains ineffective on strengthening capacity for links Population and development. The only
practical planning exercise for United Nations Population Fund support is the ongoing development of a
National Development Plan 2012-2014 in the short term by Vice Prime Minister in charge of Economy and

Industry. The Annual Work Plan of the component Population and development do not organize exit strategies.
This absence can be justified by the fact that the involvement United Nations Population Fund in the area
Population and development is very diverse, with inputs that are not vital to the operation of services National
Development Plan and agencies supported. Moreover, United Nations Population Fund during the period under
review and for component Population and development has significantly reoriented its support with the 2009
crisis, in fact abandoning activities without particular exit strategy. The cessation of activities had no
significant effect on the operation of Indicator of female participation, in which United Nations Population
Fund resources were reallocated. The abandoned activities returned to their base level, usually nothing because
of the lack of central services operating budget (as decentralized). United Nations Population Fund support is,
however, increasingly built over the long term during the period under review. The activities by the ad hoc
nature as a support service or National Integrated Monitoring Evaluation System progressed to addressing the
root causes (aging executives’ National Institute of Statistics one hand, absence of culture monitoring and
evaluation of Technical Services Devolved other), which implies, in the context of the country, a training effort
for long periods. This option has emerged for National Institute of Statistics but remains open for National
Integrated Monitoring Evaluation System.

Chapter 6 Discussions and Recapitulation
§6.1 Summary of Results
The evaluation of the Integrated Program for Quality of Care for maternal and child health in Madagascar
focused on care in 36 health facilities in the prevention and management of common complications of
childbirth. All hospitals or health centers recording more than two births per day were included in the
assessment. Health facilities were mostly public institutions (81%), almost three quarters were hospitals of
different levels (District, Regional and University) and a quarter of the level Basic Health Centers 2. The
particularity of this evaluation was that providers were actually observed during deliveries (N = 347) and
Antenatal Care (N = 323). The data from the observations were supplemented by statements of places at four
different levels (general, prenatal care, maternity, pharmacy) and interviews with 139 service providers,
including the assessment of their knowledge. The majority of observed and interviewed providers were
midwives. The analysis of several collected forms yielded a general description and timely maternal care in all
health facilities with high attendance in Madagascar. The results of the Evaluation of the Quality of Care
indicate that despite a large number of areas with a good performance, gaps remain in all stages of care for
pregnant women and newborns, which Action represents opportunities for players in the field of maternal care.
The main findings are presented and discussed below, the results have been synthesized from many data forms
collected for Prenatal Care, Prevention of infections of Labor and Childbirth uncomplicated Pre-Eclampsia /
Eclampsia, obstructed labor / prolonged labor, Placenta Previa and resuscitation of the newborn. The findings
on all the themes are also presented and discussed here. The recommendations focus on policies, the level of
training to be ready to provide services and specific service components.

6.1.1 Prenatal Care
Almost all health facilities had the basic equipment such as a stethoscope Pinard (97%) and most had
a blood pressure monitor in working order (82%). However, the findings were mixed regarding the stocks of
drugs: for example, if the tetanus vaccine was available in more than 94% of training, the Prenatal Care for
intermittent preventive treatment during pregnancy was in 62 % of these formations. The guidelines and
protocols Antenatal Care rarely (38%) were seen in health facilities. Counseling supports the Prenatal Care
were available in half of formations. Regarding the systematic components of services prenatal care, the results
are highly variable: if 88% of training offers systematically screening for syphilis blood test and 70% of family
planning, only 56% consistently offer Prenatal Care intermittent preventive treatment during pregnancy. Less
than a quarter of training (24%) offers the blood group determination.

6.1.2 Observations of Antenatal Care
During Antenatal Care providers interviewed almost all clients on the presence of a danger sign to a
minimum (90%). However, some signs were covered less frequently, particularly in relation to HIV status (less
than half of women, i.e. 40%) and persistent cough (only 3% of women). If taking blood pressure has become
routine (82%), providers will have completed successfully in 48% of cases observed. While nearly three
quarters of the women received their injections of tetanus vaccine during early consultation Antenatal care,
only half of them have received iron and folic acid and 40% received Antenatal Care. It was common that
providers ask women about the outcome of their previous pregnancies (eg miscarriage), however, they rarely
posed their questions about possible complications in previous pregnancies and deliveries. Less than a quarter
of claimants have asked the patients if they had heavy bleeding during or after pregnancy or a previous birth
and less than a fifth were asked about hypertension caused by pregnancy. And if it was common for providers

provide counseling on medical prevention interventions (e.g. Prenatal Care, iron / folic acid and tetanus
vaccines) (67-77%), it was rarer they provide counseling on birth preparedness (35%) or postpartum family
planning (20%).

6.1.3 Infection Prevention
Supplies for Infection Prevention were available in 83% of health facilities, goods whose availability was
high being: sharps containers, soap and water for hand washing and decontamination solution. However, the
availability of clean and sterile gloves was observed only in two thirds of formations. If the availability of the
sterilization equipment was relatively good (83%), half of the training had no written guidelines or sterilization
protocols. If providers have protective clothing in preparation for childbirth observed in 60% of cases, the
treatment of clothing with 0.5% chlorine solution after use was observed only in a quarter of case. The
permanence (24h / 24) is provided in more than two-thirds of health facilities studied. If all training had
electricity and almost all had to use the toilet, only half was equipped with communications equipment and
emergency transportation and only 25% were equipped with a safe water source nearby. If all health facilities
were equipped with delivery tables, they were less likely to have lamps for gynecological examination (63%).
One third of the training could not guarantee the privacy and confidentiality of patients (either in shared or
private rooms). Two thirds of health facilities had blank partographs in stock. Guidelines or instructions for
childbirth without complication were found in 28% of training and a similar proportion was recorded for those
on Emergency Obstetric Care. If two thirds of the training had essential supplies for childbirth without
complications and with only about half of them had essential supplies for the care of the newborn. Less than
half of the training evaluated maternal deaths or deaths near misses and only a third of them have evaluated the
neonatal deaths or deaths near misses.

6.1.4 Knowledge of Providers
The level of knowledge in Compliance providers and monitoring of Labor and Childbirth (average score
of 66%) was moderately high and nearly three quarter of them correctly identified the partograph is how the
right support to record observations. However, claimants were few have correctly identified the action to be
taken to prevent transmission of HIV from mother to child during Labor and Childbirth (average score of
14%). Almost all providers have indicated to reason that we should not systematically practice episiotomy and
artificial rupture of membranes; however, nearly half felt that the naso-oral suction of the newborn should be
done systematically.

6.1.5 Observations
If partographs were available in most training, providers have used them in about a quarter (28%) cases of
Labor and Childbirth observed. Virtually no provider (2%) has completed the entire curve at least three hours
during the work. If providers have consistently followed some of the early stages of evaluation of the client
(for example, ask about the age and parity, check the fetal heartbeat and perform vaginal examination), they
very rarely applied certain practices. Providers have taken the pulse and temperature of the patient in half of
the cases observed and has asked about the amount of urine in 10%. Patients were rarely asked about the
danger signs (10 to 34% on seven different characters).
During the observations, it was unusual that providers assist the mother in the start breastfeeding within
one hour of birth (37%). This figure is much lower than that recorded by the Demographic and Health Survey
where 72% of women reported having started breastfeeding within one hour of birth. The study Quality of
Care, provider performance is even lower (35-40%) when it comes to explaining the procedures to women in
labor, to encourage them to walk or change positions during labor. Providers rarely asked the women in labor
or persons accompanying them if they / they had questions (28%). However, providers often welcomed and
treated with kindness patients (65-88%). At least harmful and against specified practice was noted in the
majority of observations of Labor and Childbirth. The most common were: stretching of the perineum (68%)
and the fact of holding the infant upside down (30%). Among the cons-indicated practices observed is falls

manual exploration of the uterus (50%) and more rarely episiotomy, the nasal-oral suction of the infant and the
restriction drink while working.

6.1.6 Preeclampsia and Eclampsia
Statement and Level of formations willing to Provide Services Concerning to the Pre-Eclampsia /
Eclampsia Injectable anticonvulsants were available in nearly three-quarters of training (magnesium sulfate in
47% of them). Just over half the formations had other medications necessary for the administration of
magnesium sulfate (lidocaine and calcium gluconate). Antihypertensives were available in 50% of training and
sedatives (phenobarbital) in 25%. Assessment of Prenatal Care said more than half of the training (56%)
offered the analysis of proteins in the urine. However, less than a third of reactive formations had urine strips
in stock and have the capacity to perform analyzes on urine porridge. Some courses (15%) had guidelines on
the management of Pre-Eclampsia / Eclampsia. Almost all providers (96%) correctly established the diagnosis
of fictitious case that was presented to them, namely that it was severe preeclampsia. However, only a third
correctly identified the action to be taken to stabilize a patient and only half knew what to do in case of
convulsions. For all questions regarding the Pre-Eclampsia / Eclampsia combined, the overall average score
was 51%. If providers have taken the blood pressure of pregnant women in 82% of cases observed, they are
less likely to have used the right technique (48%). Only 29% of women have undergone a urinalysis or were
referred for this purpose. Less than a third of the women were instructed to return to the center in case of
danger signs of Pre-Eclampsia / Eclampsia (eg, sore head or blurred vision, swelling of the hands or feet).

6.1.7 Observations of Labor and Childbirth in Relation to the Pre-Eclampsia
or Eclampsia
If taking the blood pressure is systematically (88% of cases), providers have evaluated or discussed
danger signs that in half of the cases observed. Sixty percent (60%) of prepared partographs indicated that
blood pressure of the patient was recorded at least every four hours. It was rare that urine tests to detect
proteinuria are performed (7%). Ten cases of Pre-Eclampsia / Eclampsia suspicion were observed. Of the
seven cases in which these formations of Pre-Eclampsia / Eclampsia showed up, five had magnesium sulfate to
motherhood and on the inventory of the pharmacy. Diazepam was available in five formations.
Antihypertensives were available in two of the seven courses where cases of Pre-Eclampsia / Eclampsia were
observed. Among the courses where Pre-Eclampsia / Eclampsia cases have been observed, the regional
hospital had neither magnesium sulphate nor diazepam. Magnesium sulfate was administered to any case of
suspicion of Pre-Eclampsia / Eclampsia, including in training that had in stock. Diazepam was administered in
five cases. If antihypertensives were administered in at least two cases, they have not been in at least one case
where their availability was observed. If convulsions in the patient, magnesium sulfate was not administered
even if it was available. Other best either have been applied practices. Basically, the treatment with magnesium
sulfate does not seem to be a standard procedure even if it is available and antihypertensives are not
administered systematically when to do it and when they are available. The results observed in the case of
suspicion of Pre-Eclampsia / Eclampsia are consistent with those from interviews with providers, namely that
while most providers are able to define and diagnose Pre-Eclampsia / Eclampsia, only a third can describe the
appropriate management.

6.1.8 Obstruction of Labor and Work Extended
If the cesarean was performed in 64% of training, blood transfusion was offered in only about half of
them (53%). If the availability round the clock service providers (including the anesthesiologist) needed to
conduct a caesarean was observed in 70% of facilities providing this, only 64% had halothane and just a little
more half of ketamine (57%). Providers' knowledge on labor obstruction symptoms (score 45%) as well as
what to do and analyzes related to obstructed labor (average score 37%) seem relatively low.As noted above,
partographs have hardly been used; even if they were, when they begin to be used rarely correct (19%) and

very few were completed according to the frequency and degree of detail required (2%). Statement and Level
of formation willing to provide Services concerning Hyper Placenta Previa and Active Management of the
Third Period of Childbirth. If injectable uterotonics were available in three quarters of training, availability of
syringes and needles (61%) was lower. Half of the trainings had the necessary items from the placenta when
retention.

§ 6.2 Knowledge Providers
Providers had relatively little knowledge of the signs to assess the occurrence of PPH (score 56%) and
they were few to know the movements to assess uterine. Similarly, only 36% of claimants were aware of the
support stages of a retained placenta. The administration of uterotonics (oxytocin) during the third stage of
labor was observed in 85% of cases; however, it is only in 21% of cases the administration was carried out in
the minute following childbirth and following dose and appropriate way. Compliance with all procedures of
the Active Management of the Third Period of Delivery, including the dose and appropriate route,
administration of oxytocin in the minute following childbirth, controlled cord traction umbilical and uterine
massage were observed when in 13% of cases. Providers need more support and supervision to ensure the
realization of the full set of interventions Active Management of the Third Period of Childbirth. For example,
an uterotonic was administered for the Active Management of the Third Period of Childbirth in four of eight
cases of Hyper Placenta Previa in women who gave birth in a health facility while oxytocin was available in
stocks of maternity in all four cases where it has not been administered. In addition, uterine massage and
controlled cord traction have not been performed in most cases as they do not require special equipment or
supply. The manual removal of the placenta seems to have been tried in five cases although not in accordance
with the guidelines manner. The administration of uterotonic was made only for the treatment of 4 out of 15
suspected cases of Hyper Placenta Previa. In both cases, a woman who gave birth outside the health facility
and was referred seems to have had need for manual removal of the placenta without having been tried or
done. Almost all (86%) training conducted resuscitation of infants in the last three months. Most courses have
a suction bulb to resuscitation, two-thirds had a vacuum apparatus for use with a catheter and tube and mask.

§ 6.3 Findings on All Topics and Discussion
These findings highlight the specific areas for improvement to address the gaps identified in this
assessment, in particular as regards the training readiness, knowledge providers and routine practices related to
the quality of Antenatal Care, labor and delivery and obstetric care and neonatal Emergency. Some gaps have
been identified on all technical components and whatever the data collection method, namely:

6.3.1 Level Training to be ready to Provide Services
Providers and training do not have protocols for most services prenatal care, labor and delivery and
Obstetric Neonatal Care and Emergency. The guidelines and visual aids are not displayed or available in
general:Even though some essential drugs are available and staff, the use of these is sometimes compromised
by the lack of supplies and additional equipment;While 78% of the courses have an injectable uterotonics in
stock, they were less likely to have the equipment necessary for its administration (for example, 61% had
syringes, infusion sets and 56% of 42% of the suture material);The proportion of courses with supplies for
essential care for the newborn was lower (53%) than training with essential supplies for delivery (62%) or for
serious complications (67%);Assessments of deaths and deaths near misses in the new-born (33%) are less
frequent than in mothers (42%).

6.3.2 Differences between Levels of Being Ready To Provide Training
Services and Services Delivered
There is a gap between the availability of supplies / medicines and services provided. If seventy-seven
percent (77%) of the studied formations had iron / folic acid tablets, these tablets were administered in only
half of the first Prenatal Consultation.If 67% of facilities had partographs virgins, they were used in 28% of
cases observed.There is a gap between the services that providers say they provide systematic and care
observed or inventoried supplies.If, according providers, counseling on family planning was systematically
offered in 71% of training, counseling on postpartum PF was observed only in 20% of prenatal consultations.
Fifty-six percent (56%) of training would provide analyzes of protein in the urine according to their statements,
however only 29% of training do have reactive urine strips in stock or the ability to perform analysis on the
boiled urine.In at least one case of suspected PE / E, the patient was referred, even though the original training
was a district hospital that should have the ability to take over the EP and the need to apply the procedures
indicated such as vacuum assisted delivery.In many cases, interventions are not available as they require no
special equipment or supplies.In compliance with the Active Management of the Third Period of the Childbirth
in cases of hyper planceta previa, controlled cord traction was performed in only three out of eight labor and
delivery in the health facility. Similarly, uterine massage was conducted in three out of eight eligible cases.

6.3.3 Service Delivery
Of all the care components, even certain procedures and interventions were applied; the observed practice
was not optimal.Even for the 28% of cases of T & A for which providers have completed partographs, filling
was started at the wrong time and frequency adopted was not proper; If providers have taken the blood
pressure of patients in most prenatal consultations, they have done correctly in less than half the cases; If
providers administered injectable uterotonic in most cases and work delivery, they have administered within
one minute after birth and following dose / appropriate route that in less than one in five cases and only 13% of
patients have benefited from all the elements Active Management of the Third Period of childbirth; If patients
have received counseling on the tetanus vaccine in 77% of observed antenatal care, only a third of them
received counseling on birth preparedness and 20% higher on family planning post partum; When in charge of
hyper planceta previa taking interventions are made, it is generally not in accordance with the guidelines
manner. For example, aspects of appropriate practices are forgotten during manual removal of the placenta
during the observations.

6.3.4 Knowledge
This is in terms of knowledge and practices related neonatal care providers that are most lagging behind
other indicators of labor work; If more than 95% of the providers knew the nursery practices that were
dangerous or not-indicated such as episiotomy and artificial rupture of membranes, less than half knew that the
nasal-oral suction of the newborn was not a systematic practice; The knowledge providers were particularly
low in relation complications are the major causes of maternal deaths in Madagascar, including the PPH and
pre-eclampisie and eclampisie; The average score for knowledge on assessment, how to behave and the
interventions to be applied in case of abundant postpartum bleeding due to uterine / non-contracted uterus only
amounted to 39% and the score plea relating to the assessment, how to behave and the interventions to be
applied in case of retained placenta / product design was just 36%;If the score for evaluation / diagnosis of preeclampisie and eclampisie was 70%, less than a third of providers knew stabilize if using magnesium sulfate
and antihypertensive; about what to do against a woman making seizures, the average score only amounted to
50%.Providers had an easier or were more used to deliver information about medical interventions for patients
that provide counseling on health behaviors, seeking care and medical services outside the immediate context.
Therefore, there are missed opportunities to deliver essential services or reference to these services at the
ANC, labor and delivery. The level of knowledge and practice in relation to human immune virus counseling,

in screening and prevention of transmission (of human immune virus) of the Mother and Child was low despite
the fact that the corresponding services were widespread. If counseling and human immune virus testing was
available in 82% of the studied formations, providers were asked pregnant women about their knowledge of
their status in relation to HIV in less than half of prenatal consultations. In addition, the average score of
providers on issues related to PMTCT was 14%, representing the worst score for all evaluated areas of
knowledge.

§ 6.4 limits
The study is cross-cutting and is only an occasional view of the situation. In addition, it may be that
providers observed during the prenatal Control and labor and delivery are not always those who were
interviewed on systematic and practical clinical knowledge.Under the Hawthorne effect associated with being
observed, it is possible that providers have delivered better quality care than they would have done normally to
clients of SPN and maternity patients. It is possible that the results are greater than what would happen in
reality. However, knowing that the data collectors remained three and half days at each facility, it is possible
that providers have resumed their habits. It should push a little study to understand how the data was entered
correctly observed and smart phones. The tools in total had hundreds of questions and required observers to
work intensively for several days at each facility. It is possible that fatigue or quality problems are posed in the
late tools or observations conducted at the end of visit. Moreover, in the observations of work and delivery,
several interventions can occur simultaneously (eg Care Newborn Essentials and Active Management of the
Third Period of Childbirth. So it may be that the observers have missed certain aspects of care provided.
However, these fears should be weighted by the fact that observers were trained on consistent and uniform use
of investigative tools; they had the opportunity to practice on the use of tools during simulations Control
prenatal was evaluated thereafter. Because of the lack of data on the management of complications, it was
impossible to conduct a thorough qualitative analysis of certain complications. Moreover, these are not all
points of the T & A that could be observed in all cases, which is partly due to the stage of labor of women
when it comes to the health facility (for example, they can happen in the second stage or giving birth en route).
Overall, it is not always possible to tell whether the absence of data can be attributed to one of the
aforementioned problems (eg, simultaneous interventions, delay in arrival to health facilities) or an error or
simply a real lack of response (eg, intervention has not yet been launched, making that questions about his
administration should remain empty).Overall, the evaluation questions were clear, exclusive, with no overlap
in their answers. They had binary responses (yes / no) to the extent possible. However, in the inventory of
health facilities, most inventory issues had four response options: available, reported but not visible, not
available, do not know. Because the "reported but not observed" was not accompanied by any additional
information it had become equivalent to "not available" and was aggregated to this option as part of this
analysis. The questions did not determine whether stock outs observed were temporary or recurring problem.

§ 6.5 Comparison of Those Findings of Demographic And Health
Survey in Madagascar
6.5.1 Prenatal care
To give a clearer picture of maternal health services that women receive in Madagascar, it is useful to
compare the results of the Demographic and Health Survey of 2008-2009 Madagascar (DHS) 15 the findings
of the Evaluation quality care. It Evaluation assessed the quality of care received by women in health facilities,
the DHS has collected information from a sample of women nationally representative, approaching at
Community level. The comparison of the two surveys is limited to some indicators, especially regarding
prenatal. These indicators are identified and summarized below. According to health education, a high
proportion of women in Madagascar, namely 86.3%, have received their SPN with qualified personnel: 59.8%
of these women were treated by a nurse, midwife or medical assistant; and 26.5% were received by a doctor. In
comparing the results of health education on prenatal care to those in care quality evaluation, it is important to
note that education is whether the woman received specific interventions during last birth or during a birth that
occurred in the five years preceding the survey. Quality care P, education reveals that 48.7% of women who
received prenatal care at their last birth were informed of the signs of pregnancy complication.
However, if we consider the most comparable indicator of the quality assessment, the average percentage
of women who received counseling about risk signs during pregnancy is 33.1%. As regards the counseling on
the specific complications of pregnancy (e.g., vaginal bleeding) the percentage varied between 6.2% and
36.6%. Among the women who received prenatal care during their last birth, education notes that the claimant
took their blood pressure in 80.6% of cases. This figure is very close to that of the health care quality
assessment, which is 82%; however, care quality evaluation indicates that the claimant has used the right
technique in 48.4% of cases. According to education, 29.5% of women have been the subject of a urine sample
as part of prenatal care during their last delivery. The most comparable indicator of prenatal care is an
assessment similar percentage, namely that the service provider has performed a urinalysis (or referred the
woman to such analysis) on 28.9% of the cases observed in prenatal care. Education is that 59% of women
who had a pregnancy in the five years preceding the survey report taking iron tablets or syrup. If the
comparison can only be very brief because of the difference indicator, it is interesting to note that the
Assessment quality notes that 53.7% of women have been prescribed or received iron tablets or folic acid or
both at their first prenatal visit. Educating notes that 47.4% of women received a minimum of two injections of
tetanus vaccine during. Their last pregnancy, while care quality assessment indicates that 57.8% of women
observed in the context of quality care are received an injection of tetanus vaccine. As for malaria, according
to education, 48.4% of women who gave birth in the last two years said they had taken a drug during
pregnancy. However, only 11% reported receiving Fansidar during antenatal care and only 6.4% said they had
received two or more doses of Fansidar during care. However, the quality of care assessment notes that 40.1%
of women observed during prenatal care received malaria prophylaxis.

6.5.2 Care Childbirth and Breastfeeding
In contrast to the high use of SPN from qualified health providers, education notes that only 35% of
births occurred during the five years preceding the survey at national level have taken place in health facilities.
It is therefore difficult to compare the results of education and Evaluation Quality of care in terms of care
related to childbirth. Nevertheless, it is interesting to note that education notes that 1.5% of births in the last
three years were caesarean sections. However, as part of the Assessment Care Quality, 11.5% of deliveries

were done by cesarean section, reflecting the fact that the sample of the quality of care was limited to health
centers. One of the major points of difference between Education and assessment is the indicator on
breastfeeding. Education notes that most women started breastfeeding soon after birth, up 72.4% in one hour
and 92.2% within 24 hours after delivery. According to the Evaluation, only just over a third of mothers (37%
of observations) did not receive support to start breastfeeding within one hour. This difference could either
indicate that mothers initiate breastfeeding on their own, without the assistance of a service provider, or mean
that there are unresolved differences between the sample and the Evaluation of 'education. But Education also
notes that women who have benefited from the assistance of a skilled attendant during childbirth are more
likely to start breastfeeding within one hour of birth than those who gave birth with using a traditional birth
attendant (76% against 70%). Similarly, women who gave birth in a health facility were more likely to initiate
early breastfeeding than those who gave birth at home (77% against 70%). It might be useful to look more
closely at the low starting rate of breastfeeding found in the Evaluation.

Chapter 7 Recommendations or Contribution
§ 7.1 Recommendations Regarding National Policy
The findings open the door to a number of recommendations for policy and program to enhance the
quality of maternal and neonatal care in health facilities in Madagascar. At the national level, key stakeholders
from different institutions and disciplines should meet to discuss and develop strategies to address the findings
of this report. National policy documents have been developed to facilitate high quality Health Maternal and
Neonatal. They include the National Reproductive Health Policy, the National Hospital Policy, the Road Map
for the Reduction of Maternal and Neonatal Mortality for 2005-2015 and document standards or standards
listed in Appendix 2. Although these documents are made available to health workers, it is necessary to
provide training, supervision and the provision of equipment, materials and medicines to health facilities. As a
key recommendation, we should develop an implementation plan to accompany and operationalize health
policy documents for training and health workers are well prepared to provide health services Maternal and
Neonatal quality every woman pregnant and every newborn. The evaluation showed that simple techniques
such as the management and supervision of the work using the partograph, prevention of PPH by Active
management of the Third Period of delivery using sulfate magnesium for the prevention and treatment of
epiclampsie are not common practices among healthcare providers. Again by way of key recommendation
should be to develop a mechanism for distribution to providers of technical updates and data sheets. These
technical updates should contain the most recent evidence for routine service delivery of interventions mother
and neonatal essential. Stakeholders and donors have the opportunity to work together to address gaps and
deficiencies identified by the study quality service.
Other recommendations are: Discuss the responsibilities of institutions at all levels of the health system
regarding maternal and neonatal care, including the minimum number of providers in each type of facility, the
minimum package of activities and expected resource package minimum required with stakeholders; Review
the classification of courses they offer according Obstetric Neonatal Care and Basic Emergency Obstetric work
and Neonatal Emergency complete, depending on the actual resources available at each institution and the
update classifications training on the basis of regular monitoring of available resources and quality of care;
Advocate for all effective drugs for the prevention and management of common maternal and neonatal
complications are on the List of Essential Drugs of Madagascar; Ensure that all health facilities have
conspicuous guidelines for full benefit, correct and consistent critical interventions such as screening during
prenatal care, essential newborn care and resuscitation of the newborn; Evaluate all existing documents (eg
curricula, data sheets, guidelines, protocols) on care, childbirth and work and if necessary, update them and
correct them; Updating the initial and ongoing staff training to ensure that maternal and neonatal services are
aligned with the best practices and evidence recognized worldwide; Insist on respect for national guidelines in
the practice of prenatal care, childbirth labor and obstetric care and Neonatal Emergency and for appropriate
PMTCT detection of eclampsia, Obstetric and Neonatal care and Emergency the elimination of harmful
practices and not given during labor and delivery; To identify innovative approaches for involving trainers
already in place, including universities, in order to ensure that all trainers have the knowledge and basic skills
up to date. Support training programs to allow moving from one-off workshops serial training modules that
enable two-way feedback and tracking / monitoring the adoption and retention of new skills; Incorporate
observation and inspection schedules for the clinical supervision of practice; Integrate appropriate indicators of
care in the Information System for Management of Health.

§ 7.2 Recommendations for All Components and Related to the
Level of Health Facilities to Be Ready to Provide Services
Disseminate and explain instruction manuals, protocols and visual aids for critical care procedures and
services, IP, delivery work and Obstetric Neonatal Emergency Care and in health facilities. Check availability
systematically. Ensure the availability of essential facilities such as running water and electricity is a standard
in all health facilities; Ensure that all health facilities are provided with the supplies, equipment and basic
medicines necessary for the provision of essential interventions for prenatal care, labor, and Neonatal Obstetric
Care and Emergency (for eg, syringes, urine strips, clamps / umbilical cord clamps); View the list of the
minimum package of hardware resources (according to the document of national norms and standards set out
in Appendix 3) in all prenatal care rooms, work and Obstetric Neonatal Emergency Care and to remind the
minimum standards for providers and supervisors and support in advocacy for the availability of these
resources in their minimum training; Ensure respectful treatment and care of women and their families. Ensure
privacy and confidentiality in the rooms of consultation and work. Ensure provider training goes hand in hand
with the availability of equipment or supplies and conversely that staffing in new equipment is accompanied
by training on the use of the equipment; Strengthen monitoring systems to promote compliance with the
national policy and clinical guidelines in the delivery of routine services and the management of emergencies.
In an implementation report on the collection of data Quality of care in Madagascar, it was proposed that
the implementation of the recommended actions and recommendations by component gives priority to health
facilities that provide clinical training which is in areas with high rates of maternal and neonatal mortality, or
remote areas where the reference is difficult. The report also noted inefficiencies in the organization of health
facilities and recommended cross-cutting measures to be implemented in health facilities, including. Simplify
and facilitate the administrative procedures in hospitals, particularly regarding the identification and
management of indigent patients; Improve patient care night security; Improve collaboration between health
workers and paramedics; Develop processes that allow the transfer of information and records of complete and
systematic cases between guards or teams of health workers; Have individual records on each patient that are
accessible to all health care staff responsible; Have safety and monitoring systems to ensure proper use and
maintenance of equipment and supplies in health facilities for which they were acquired.

§7.3 Recommendations by Component
Ensure that providers have guidelines for prenatal care services, particularly in the detection and
management of Sexual transmissible infection, and for HIV counseling, HIV testing; Ensure that providers
have the visual aids and other necessary supports to be able to provide a comprehensive counseling on all
essential interventions as part of prenatal care, and have a discussion of family planning, post-partum Family
Planning and exclusive breastfeeding; Ensure that providers have equipment in working order (eg,
sphygmomanometer, stethoscope) for prenatal care services and be trained in their proper use; Strengthen
training and supervision for prenatal care to ensure the compliance of the services with the guidelines (eg
taking blood pressure in optimal conditions, taking the temperature and pulse and supply of Public Health for
malaria prevention); Improve waste management by consistently using sharps containers and providing all
incinerators training in running, non-polluting and sustainable; Ensure that providers have a different set of
protective clothing for each client and encourage the systematic processing of clothes with 0.5% chlorine
solution after use.

7.3.1 Labor and Childbirth
Provide training and ongoing support to improve interpersonal communication, including the
explanation of procedures during labor and delivery, encouraging patients to ask questions and specific topics
such as Postpartum Family Planning; Provide guidance and technical data sheets for counseling on PreEclampsia / Éclampsiependant the prenatal care as well as for the diagnosis of proteinuria; Provide guidance,
provide ongoing training, to advocate and provide supervision necessary to ensure the identification and the
management of PE / E (including the use of magnesium sulfate and antihypertensive and the diagnosis of
proteinuria). It may be necessary to identify the barriers that prevent the use of magnesium sulfate, even
though it is available or barriers to the provision of appropriate first aid at the level of training, the problems
documented in the case of Pre- eclampsia / eclampsia observed during evaluation.

7.3.2 Obstruction of Labour or Work Extended
Provide guidance, provide ongoing training, to advocate and provide supervision necessary to ensure the
appropriate use and filling partographs as a tool for managing work at the time of delivery; Provide guidance,
provide ongoing training, to advocate and provide oversight to ensure the full benefit, correct and timely of all
three components of the Active Management of the Third Period of Childbirth. As noted in the Global Report
on the Status of HPP programs and eclampsia 2011, the Active Management of the Third Period of Delivery is
included in the initial and continuing training but not in the service delivery guidelines ;Provide guidance and
retraining and get the equipment / medications for proper treatment of PPH. This includes supervision for
interventions such as manual removal of the placenta is in compliance with the guidelines; Provide guidance,
provide initial training and on the job training, to advocate and provide supervision necessary to ensure the
systematic monitoring and care of the newborn in optimal hygienic conditions. A preliminary meeting of
stakeholders on the findings of the observation of the strategy was held in February 2011 and a final
dissemination plan covering this report is expected in January 2012. The contribution of stakeholders is
essential if we really want take into account the conclusions of this report and a concrete implementation plan
in order to improve maternal and newborn health in Madagascar and achieve the Millennium Development
Goal for Development.

ACKNOWLEDGEMENT
I thank my God Jesus Christ our Lord, my family, bringing that encourages and loves unconditionally. It
is certainly the source of all inspiration, all transcendence How to read, write and think every day without
knowing that they are there, the people who are dear. You never really told them they represent everything for
us and affection that bears their deep within our heart. While this document may be a way to tell you how I
feel. My wife and my three children: Joda, Efesiana, Finoana. Finally, thank you to my wife and my children,
near or far, for their support and love.
I hope you will understand later that nothing and nobody can replace a father passionate and courageous
in a lifetime. I completed graduate studies at least 26 years studies from 1989 to 2015. My sisters, my only
brother, friends are wearing your dreams, your hopes and your efforts daily. I started these adventure strong
examples of work and effort that accompanied every day my family. I continued driven by love for all. I
thought to give up a thousand times, but I never wanted to show you a dad who gives up. Maybe one day those
words will help you realize your dreams.
I thank Professor, YANG SHUWANG, without it, the work would not be possible. He encouraged me
and supporting me throughout these years. His advice guided my research and allowed me to move over these
four years. Despite the distance, availability and confidence helped me a lot in this work. I tines thanked
Professor YI MING is Professor associate this research and moral support. It has a lot of responsibility, but it is
even encouraged for long years.
I thank the members of the jury of this thesis have agreed to be members
My jury and evaluate my work in time constrained. I thanks to the personal in the University of
Geosciences in Wuhan, Hubei, China agreed to receive me and especially the Leaders studies in China. They
gave me access to study in the People's Republic of China, unforgettable experiences. I would like to thank the
more our government in Madagascar, the Ministry of Higher Education, Ministry of Public Health and Family
Planning. The CONABEX, All my friends and students and Malagasy prayer cell in China.

References
[1]Heriniaina Mandanirina. Demographic and Health Madagascar [M]. National Institute of Statistics.INSTAT
and ICF Macro. Antananarivo. Madagascar. 2009.
[2]Hantaniaina John. Management Department Context of Health in Madagascar [M]. The Health Service.
Antananarivo, Madagascar.1992.
[3]Miandrisoa. Evaluation of Department Management Health [M]. Staff of Administrative record SALFA.
Antananarivo, Madagascar.2008.
[4]Pihanina.R. Management Public and Health Development [M]. Ministry of Health, Ambohiday,
Antananarivo.Madagascar.2004.
[5]Razanamiadana, Rakitsoratra Notsongaina. Compendium of Visits Volahavana Germaine [J]. Faculty of
Theology in Madagascar. 2007: 2-3.
[6]John. KT. Manager in Department Health [J]. Building Plan and the Beginning of the Story. Manager of
Lutheran Hospital Madagascar. 2003: 23.
[7]Andrianarivelo R, Randretsa. Management and Population of Madagascar[M]. Location Current and future
perspective. 1981: 12-13.
[8]ARMENGAUD André,REINHARD Marchel R.General[M]. History World population. Mont Christian
Editions, Paris, French. 1989.
[9]Coale Ansley, Moover Edgard.M. The influence of Economic Development on Population Growth
[M].Service Population in Madagascar.2001.
[10]Levelo Marcellin. History of Management in Madagascar Africa [J] Ambatofianandrahana, Madagascar.
1999.
[11] Gavirneni, S., Kapuscinski, R., Tayur. Value of information in capacitated Health [M]. Graduate School
of Management Administration, Management University. 2008.
[12]Sauvy Alfred. “Who am I? [M]. its laws, its balances. PUF, Paris, French. 1934.
[13]Geraud R. Birth Control and Editing General union [M]. Paris by saps editions. Paris 56. 1998.
[14]Geraud R. Birth Control third Editions [M].Paris by saps editions. French.1998.
[15]Paopertj.M . Birth Control and Theology [M]. Edition du Seuil Paris. French.1997
[16] Obaka Kaosha.The Center for Communicable Disease Control (CDC). The center of the Promotion of
health education. Division of Reproductive Health. Methods and practices for Africa, Atlanta, Georgia
30333. United States of America. 2003.
[17] Rahantamalala Honorine. Ministry of Health. Family Planning and Social Protection [M]. Guide Family
Planning practice for health workers.Antananarivo.Madagascar. 2007.
[18]Lalao. Family Planning and Social Protection [M].Family Planning Branch. Andohalo, Antananarivo,
Madagascar.2001.
[19]Rasoanavoarilala Haritiana Sylvie. Family planning for the well being of the Malagasy family [J].Health in
Antsirabe. 2011:25-26.
[20]Fydelis Rakotomanga. Family Planning and Social Protection. Family Planning Branch[M]. Andohalo
Antanarivo.Madagascar. 2009.
[21]Andrianasolo Maminirina. Family Planning and Health Management [M]. Service of Management,
Madagascar. 2007.
[22] Honore Rambeloson. Plan in Family Planning in Madagascar Action Plan [J]. Paris by saps editions. Paris
5 1998: 45.
[23]RAZAFIMANJATO Jocelyn. Perspective and Population projection in Madagascar [M]. Department
Management in Madagscar.2006.
[24]Rabenandrasana Henri. Investigation Demographic and Health [M]h. National Institute Statistics. Ministry
of Health, Antananarivo, Madagascar.1996.
[25]Narasimhan R. A social exchange theoretic study of sourcing arrangements in buyer supplier relationships
[J].Journal of Operations Management, 2009:373.

[26]Das T K. A resource-based theory of strategic [J].Journal of Management, 2000: 30.
[27]Bhagwan Jay, Kevin Wall. Local Public-Private Partnerships for Management Services Franchisee
Operation [M]. International conference on department management and technology applications in
developing countries, Antananarivo:2007
[28]Lise Breuil. Renewing the Public-Private Partnership for Management Services in Developing Countries.
Doctoral thesis of the National School of Management Sciences Engineering , specialty Management
Camerou, Africa: 2000.
[29]Lucille clot. Domestic management in a town of Tamil”Nadu: use and practices“Master thesis of the
French Institute of Pondicherry. French, 2005.
[30]Charreaux Gérard. Positive Agency Theory: reading and rereading. In Gerard Koenig New theories to
manage the business of the XXI century, Paris, Economica, 2003: 60-141
[31]Bertrand Dardenne “The Role of the Private Sector in Rural or Peri-urban Management Services in
emerging countries “Background Issues Paper for OECD Global Forum on sustainable development,
Paris, French. 2006.
[32]Dan Gallin. Social rights and the Informal Sector”Sixth Summer University ACMACO. Gammarth,
Tunisia. 1999.
[33]AMG Association of Management in German Foundations Social Franchising. A Way of Systematic
Replication to Increase Social Impact, Berlin, Bundesverband Deutscher Stiftungen. 2004.
[34]Meike van Ginneken, Tyler Ross & David Tagg Can the principles of franchising to be used. International
Review 2004: 342.
[35]M S. Improve management supply and sanitation services?Background Issues Paper for OECD Global
Forum on Sustainable Development, Paris, French. 2006.
[36]Meriem Aït Ouyahia Public-Private Partnerships for Funding Municipal department Management
Infrastructure: What are the Challenges? [J]. Discussion Paper, Policy Research Initiative Project,
Sustainable Development. 2006
[37]Anne-Claire Pache, Chalençon Geraldine “Changing scale, towards typology geographic expansion
strategies of social enterprises”International Studies Review Cooperatives and Mutual Associative. 2007.
[38]JE La Coussaye, F Braun.Full Management. Power or White Hospital Plan [J]. Review of SAMU
Emergency Medicine. Marseille, French. 2011:4-5.
[39]Manganirina Fenitra. The Management of Emergencies [J].Archive Circular.SCB II.IKalalao,Fianarantsoa,
Madagscar. 2014: 15-16.
[40]Andrianirina Olivier. The Development of White shots of Health Facilities and Expanded White Planes
[M]. On circular Legist France. 2006.
[41]Fanomezanatsoa Fenotiana. Management Hospital clinical in Madagascar [M]. The Health Service.
Antananarivo, Madagascar.1990.
[42] Fikambanana Mpitsabo.The Preparation Health of System Management. 2014
[43]Ammirati C, M Slama, De Cagny B. Using and organizational modalities of a white map on the scale
of a health facility [J]. Department Management Reanimation, 2011: 4.
[44] AZud Benoit. Factory favorate in Social Management [J]. Toulouse, 2001:17-19.
[45]P. Camphin.Faced with the crisis. The Establishment of White Plan [J]. Cahiers Hospital. 2008: 243.
[46]Secretariat of Protocol. White Plan of Health Management [M]. Service Management
Antalaha.Madagascar.1997.
[47]E Bertrand, Mennetrier V, J Schalter, Weissenburger J, L Blanchet, A Desroches. Compliance of
a White Plane [J]. Hospital Managements. 2008:477.
[48]Dr. Puget Dr Duponchel. The Expanded White Plane of Department Management [J]. 2013:544.
[49]Hélène de Tiesenhausen. Guide for the Evaluation of Crisis Management Arrangements at the Hospital [J].
Press EHESP,2009: 94.
[50]Association Fahasalamam-bahoaka. The Ministry of Health and of public health plans[M].
Madagascar:2011.
[51]C Virenque.White Plan Mass Casualty Resuscitation. Health establishment Archive[M]. Management
Sercive.Anosibe, Madagascar.2004.

[52]Mioran’Andrianary Miarinjo. Organization and Project Management Health[M]. SALFA Antananarivo,
Madagascar. 2008.
[53] Khan S, Wojdyla D, Say L, Gulmezoglu AM, Van Look PA. WHO Analysis of causes of maternal death a
systematic review [J]. Analysis by WHO of the causes of maternal mortality: a systematic review) Lancet
2006; 367: 1066-1074.
[54] Fikambanana Fahasalamam-bahoaka. Proportion of births by a skilled health worker [M]. Department of
Reproductive Health and Research Attended Geneva, Switzerland: WHO.2008
[55] Stanton C, Armbruster D, Knight R, and al. Use of active management of the third stage of labor in seven
developing countries [M]. Use of Active Management Of The Third Course Of Seven Labo In
Developing Countries. 2009.
[56]CK Prahalad, Hart Stuart. The Management at the bottom of the pyramid, Eradicating poverty through
profits, Upper Saddle River. Management School Publishing. . 2005
[57]Riveline Claude “A perspective on Engineering Management Organizations. Review French Public
Administration1991: 355-366.
[58]Rasoanirina Marte. Assessing the Costs[J]. Elements of a Management Theory. Paris, Presses the School
of Management and social. 2005:78.
[59]Smith E. A Project to Develop a Blueprint for Family Planning and Franchising, other Reproductive
Health Services. Marie Stopes International Working Papers, 1996:2
[60]Anita du Toit . Social Management as Organizational Format-An Overview.[J] Pretoria, Management.
1996 : 89.
[61]United Nations Development Programmer Human Development. Beyond scarcity[M]. Power. Poverty and
the global Management crisis. New York. UNDP. 2006.
[62]Valfrey-Visser Bruno, David Schaub-Jones, Bernard Collignon .Access through Innovation. Expanding
Management Services Delivery through Independent Network Providers. Building Partnerships for
Development in Management and Sanitation. 2006.
[63]Richard Walther. Vocational Training in the Informal Sector. Working Paper French Development
Agency.2006: 15.
[64]Rasoavelo Marie. World Bank Management Demand Research Team Demand for Water in Rural Areas
Determinants and Policy Implications. World Bank Research Observer. 1993: 47-70.
[65]Yen Marie. Manual for the implementation of the project in 1001 fountains[M].Internal Report 1001. 2007
[66]Patnayakuni, R., Rai, A., Tiwana, A.Systems Development Process Improvement: a Knowledge
Integration Perspective[J]. IEEE Transactions on Engineering Management . 2007: 286–290.
[67]Orders issued by public work of Madagascar by Decree 026- PM/SGG/OJ [D] by Malagasy law. 1982
[68]Dr.Fenomanana.Evaluation of Information System and Administrative[D]. SALFA, Andohalo 133
assessment of service decitoxication. Madagascar. 1996: 28.
[69]Secretary General of the association of awakening in Madagascar[J]. Innovation and Strategic
Management Health in Madagascar. 2012:78.
[70]Bruno Rabaroela. The Mission and the Life of the Nation[J]. History of Management Malagasy Lutherana
Church. 2007:2.
[71]Dr Endor Modest, President Lutheran Church.Management. Mission in South-South Project
[J].Department Management SALFA Andohalo, Madagascar. 2006: 6-7.
[72]Akinkugbe. Management History and Situation in Country[J]. With
Bertrand E. Pradel ed,
Paris,French, 1995: 1-7.
[73]Nissinen A, Bothig S, Granroth H, Lopez Ad 1988 and Coll . Management Health in Developing
Countries [J]. World Health Stat. 1986:141-54.
[74]Nimaga K, Desplats D, Doumbo O, Farnarier G and Coll.Management Health and Monitoring of
Population in Rural Madagascar[J].Bull World Health Organ. 2002:532-533.
[75]Desplats D, Kone Y, Razakarison C. For General Management Community of first line[J]. Med Trop
,2004 : 539-44.

[76]Douglas Jg, Bakris Gl, Epstein M and Coll. Management of hospital in Madagascar. Americans:
consensus statement of the management in Madagascar Americans Working Group of the International
Society on Hypertension in Blacks[J]. Arch Intern Med; 2003(163): 525-41.
[77]Carvalho Jj Baruzzi Rg, Howard Pf and Coll.Management Strategic in four Remote Populations in
Country Study. Management INSPC; 1994: 238-46.
[78]Poulter N, Khaw Kt, Hopwood Be and Coll 1984. Blood Pressure and its Correlates in an African
Tribe in Urban and Rural Environments[J] . Epidemiology Community Health. 2004: 181-5.
[79]Poulter N, Khaw Kt, Hopwood Be and Coll. Department Management in Various Populations[J].
Population Service. 2002: 197- 203
[80]Fiangonana Loterana Malagasy, The JAIRO. Study Background, Methods and Main Results. Cooperative and Management association for Counseling ADIS Personal Group.2006: 283-8.
[81]Omoe Kc, Sess Guelain J. Study of Management Middle Malagasy [J].People . Med Trop . 1993: 173.
[82]Shaper Ag, Wright Dh, Kyobe J. The Statistic and Activities of Densities in Tribes of Northern
Madagascar”. 1989: 273- 81
[83]POULTER NR. Influence of Rural and Urban Lifestyles on the Prevalence of Health Management.“
Edited by E. Bertrand Pradel ed, Paris. 1995: 26-36.
[84]Lawson, B., Petersen, K.J., Cousins, P.D., Handfield, R.B., “Knowledge sharing in inter-organizational
product development teams: the effect of formal and informal socialization mechanisms,” Journal of
Product Innovation Management 26. 2009: 156–172.
[85]Fikambanana WHO/ISH, World Health Organization/International. Society of Department Statement
on Management Health. FNUAP, Madagascar. 1998:12.
[86]Chobanian Av, Bakris Gl, Black Hr. The Seventh Report of the Joint National Committee on
Prevention, Detection. Evaluation the department Management.Mahamasina Antananarivo,
Madagascar.2003:72.
[87]ESH/ESC. European Society of management Health [J].Society of social and strategic
management,2003: 53.
[88]Frederic Ginior. Needs Assessment of Emergency Obstetric and New born Care [J]. Data Collector's
Manual. Needs Assessment In Emergency Obstetric and Neonatal Care AMDD. New York. 2010.
[89] On Acremont V Landry P, Mueller I, Pecoud A, B. Genton “Clinical and Laboratory Management
Department year in Outpatient Setting. an aid to medical decision making in returning travelers with
fever. Am J Trop Med Hyg;2002: 481.
[90]Kyabayinze DJ Asiimwe C, D Nakanjako, Nabakooza J, H Counihan, Tibenderana JK. Use of
RDTs to Improve Heath and case management at primary health care facilities in Madagascar. J. 2005 :
200.
[91]Faye A, P Ndiaye, Diagne-Camara M, et al. Economic Evaluation Management 'in Public Health.
2006. 617..
[92]Harvey SA, Jennings L, M Chinyama, Masaninga F Mulholland K Bell,DR. “Improving community
health worker use of management health”: package instructions, job aid and job aid-plus-training.
Malar J;2008: 160.
[93]Skarbinski J, PO Ouma, Causer LM. Effect of Strategy Management of uncomplicated problem in
Madagascar: a cluster randomized trial. Am J Trop Med Hyg. 2009 : 26.
[94]A Ratsimbasoa, RandrianarivelojosiaM, P Millet, Use of prepackaged Medicemament for the
management of the site in Malagasy people. Malar J 2006: 79.
[95]Julien J.From Know-how to Show-how? Questioning the Role of Information and Communication
Technologies in Knowledge Transfer [J]. Technology Analysis & Strategic Management,1996: 429443.
[96]Simons R. Analysis of the organization characteristics related to tight budget contemporary accounting
Review. 1993: 127-143.
[97]Simon R. Role of management Control System in creating Competitive Advantage New Perspectives:
Accounting, Organization and Society,1993: 357-374.

[98] Monica Valery. National Coordinating Agency for Population and Development [M]. Ministry of Public
Health and Sanitation, Kenya 2005.
[99] Jairo Fikambanana. The World's Women and Girls, Data Sheet [M]. Women and girls around the world fact sheet Washington PRB. Population Reference Bureau. 2011.
[100]Andrianirina. Demographic and Health Madagascar [M]. National Institute of Statistics and ICF Macro.
Antananarivo, Madagascar: INSTAT and ICF Macro. 2010.
[101]Sahondra Feno. Trends in Maternal Mortality [M]. Estimates made by WHO, UNICEF, UNFPA and the
World Bank. Geneva, Switzerland.1998.
[102] Fanjasoa Mirana. Evaluation needs of obstetric and neonatal care emergency in Madagascar [M]. World
Health Organization. Antananarivo, Madagascar.2010.
[103] Fujioka A, Smith J. Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia [M].
National programs in some countries.Mahamasina Madagascar. 2009
[104]Simon R. Strategy Orientation and Top Management Attestation to control System. 1992: 76.
[105]White, R.E “Generic Business Strategy, Organization Context and Performance: an Empirical
Investigation,” Strategic management journal. 2003: 217- 231.
[106]Wriley L,Divisional Autonomy and Diversification. PhD D. Diss, Harvard Business School.1998: 37.
[107]Pierre Anhoury and Gerard Viens “manager the quality and risk to hospital” ESF EDITOR. 1996: 23.
[108]Bernard Dubois. Marketing management hospital. Berger- Levrault,2003 : 99.
[109]H.Leteurte J PhD, Deborah training of hospital personal Editions ENSP” Arch in Antsirabe . 2002.
[110] Manandraibe .Pregnancy, Childbirth, Postpartum and Newborn Care [M]. Guide for Essential Practic
Toolkit for the Integrated Management of Pregnancy and Childbirth. Geneva, Switzerland.2002
[111] Hajamanampisoafeno Maminirina. Quality of Care In The Prevention and Management of Common
Complications in The Mother and The New Born [M]. Health facilities in Madagascar.2005.
[112] Kotomena. Managing Complications in Pregnancy and Child Birth [M]. A Guide for Midwives and
Doctors. Geneva, Switzerland. 1989.
[113]Pierre-Noël Giraud, Maria Augustin, Joel Ruet & Zerah Marie-Hélène. The Stakes Institutional and
Technical Development of Urban Management Infrastructure in Developing Countries Developing. The
case of Madagascar. 2003.
[114]Institute for PPP “Performance Indicators Water and Sanitation. Charter of Local Public Services.
Working Group Report. 2004: 45.
[115]Michael Jensen and Meckling William “Theory of the firm. Managerial behavior, Agency Costs, and
Ownership Structure”Journal of Financial Economics. 1976: 305-360.
[116]Lyla Mehta. Management for the Twenty-First Century [J]. Challenges and Misconceptions. Institute of
Development Studies Working Paper. 2000: 111.
[117]MIGNAVAL Philippe. Proposals to Encourage the Development of Small and Medium African
Businesses [M]. High Council for International Cooperation. 2008
[118]Dominic Montagu. Franchising of health services in low-income countries. Oxford University. Press
Health policy and planning.2002: 121-130.
[119]Annie Montaut .English Geopolitics: English in Madagascar and the Role of the Elite in the Project
National. Herodotus. 2004:115.
[120] National Institute of Statistics (INSTAT) and ICF Macro. Demographic and Health Madagascar
[M].Department health state and INSTAT ICF Macro. Antananarivo, Madagascar. 2010.
[121] MCHIP, Jhpiego, Tandem. Assessment of Quality of Service for the Prevention, Identification and
Management Of Maternal and Neonatal Common Complications. Work Report.Mahamasina.
Madagascar. 2007.
[122]Reyburn H, R Mbatia, Drakeley C of Management. Organization population in Madagascar has
prospective study.2004: 329.
[123]Rakotoarivelo, Andrianasolo R, R Rakoto Sedson, Randria MJ,Rapelanoro Rabenja F. Quick
Management Practice at the Village of Mahitsy. The Malagasy experience. Med Trop. 2010: 103.
[124]Van Dillen J, AJ De Jager, De Jong I,Wendte JF. Study of health management in hospital in
Madagascar.2007:185.

[125]Batwala V, P Magnussen, Nuwaha. The trategic Management. Department Management in
Manakara.Madagascar 2010 : 349.
[126] AM Oliveira, J Skarbinski Ouma PO. Performance of management as share of case management in
Madagascar. Am J Trop Med Hyg. 2001:4-5.
[127]On Acremont V, Kahama-Maro J, N Swai, Mtasiwa D, Genton B Lengeler C. Reduction of
Management Problem Consumption After Rapid Solution Tests in Dar es Salaam: a before-after and
cluster randomized controlled study. Malar J 2010: 107.
[128]O’BRIEN E, ASMAR R, BEILIN. Society of Management Recommendations for Conventional,
Health. 2003: 821-48.
[129]LEMOGOUM D, SEEDAT YK, MABADEJE AF Recommendations for management of Health in
Madagascar. 2004: 21.
[130]Rakotoarivelo RA, Raveloson HF, Andrianasolo R, Razafimahefa SH, Randria MJ. Aspects of
Management Health and Factors Excellent”. Antananarivo, Madagascar. Pathol Exot 2009.
[131]Rivo, Management south. Madagascar. Expansion Program and the Patronization Privet’s community
physician facilities. Health South, Marseille. 2008.
[132]Robinson JL. National Policy on Health Management. Department of HEALTH and Family Planning,
Republic of Madagascar,Antananarivo,2005: 36.
[133]Nasolo Nirina. Strategic Health and World Health Organization. Communicable Diseases Cluster. Trans
R Soc. Trop Med. 2000: 90.
[134]Manajary. Ministry of Public Health Official and Directory of Industry Statistics. Health of Madagascar.
Ministry of public health officials, Republic of Madagascar.2010: 689.
[135] Rabarijaona LP, Ariey F, Matra R, et al. Low Autochthonous Urban Management in
Antananarivo, Madagascar. Manager J 2006: 27.
[136]Rabarijaona LP, Rabe T, LH Ranaivoand health in Highland plants of Madagascar. Control strategy
against poverty. Med Trop. 2006: 66.
[137]Chandramohan, Jaffar S, Greenwood B. Use of Management algorithms for implementation
strategy”. Trop Med Int Health. 2006: 45-52.
[138]Mwangi TW Mohammed M, H Dayo, Snow RW, Marsh K. Management. Lack utility algorithms
for activities among people of different ages groups. Trop Med Int Health. 2006: 530.

Annex 1: List of Participating Health Facilities to Stud

Annex 2: Table of frequency District

Annex 3: Strengthen the Provision of Quality Health Services to the
Entire Population

200
2008
7

2009

2010

Q Q Q Q Q Q Q Q Q Q Q
Q3
4 1 2 3 4 1 2 3 4 1 2

Q4

Objective Strengthen the provision of quality health
1
services to the entire population
Activity
1.1

Contract health-care workers in the marginalised
x x x x x x x x x x x x
health care facilities

Activity
1.2

Identify the factors (geographical, financial and
cultural) that limit the use of the services
through field research

Activity
1.3

Pilot strategies in around 5 SSDs aimed at
increasing the use of the services based on the
results of the assessment study (see activity 1.2)

Activity
1.4

Carry out renovations (painting, purchase of
furniture for receiving patients, roofing, ceiling
etc.) 15 CSBs per year with the aim of x x x x x x x x x x x x
improving their physical appearance and making
them more welcoming to patients.

Activity
1.5

Head-up PTA ratification missions: the central
team of the ministry and partners will be
deployed in the regions and will ratify the PTA
in the field, instead of having the PTA sent to
them centrally.

Activity
1.6

Equip 10 SSDs with a 4x4 vehicle, the center
supervisors with 2 vehicles and 120 CSBs with
motor bikes.

Introduce different strategies for increasing the
population’s financial accessibility to health-care
services in 5 SSDs: Mutual health organization
system
Objective Improve human resources management of the
2
health sector
Activity
1.7

Activity
2.1

Contracting activities (see 1.1)

Objective Increase the mobilization and allocation of
3
financial resources

x

x x

x x x x

x

x

x x

x x

x

x

x x x

x

Activity
3.1

Offer training on financial and programmer
management to the managers on the periphery of x
the targeted districts

Activity
3.2

Strengthen the application of the Equity Funds
and mutual health organization system
implementation plan in the targeted health care
facilities

Activity
3.3

Carry out financial auditing and supervision of
the priority health-care activities with PEV as
top priority (focused on the continuation of child
and maternal care) in the targeted areas and
develop corrective strategies for improving the
programmer management.

x

x

x

x

x

Objective Stimulate demand and use of the health
4
services
Activity
4.1

Carry out a regional mapping of the NGOs and
associations working at a community level

Activity
4.2

Convene 3 meetings per year with 160 local
authorities in the targeted areas.

x x x x x x x x x x x

Activity
4.3

Convene meetings for drafting policy documents
establishing community health strategies
(including Reference Terms and a Minimum
Activity Package (PMA))

x x x

Activity
4.4

Provide training for community health-care
workers in PCA in 40 targeted SSDs. This
training includes the provision of an IEC PEV
kit including IEC aids, guides, supplies and
management tools.

x x x

Activity
4.5

Strengthen the application of the Equity Funds
and mutual health organization system
implementation plan in the targeted health care
facilities (see also activity 3.2)

x x x

x x

Objective Strengthen and institutionalize a monitoring
5
and evaluation system
Activity
5.1

Provide training for health-care workers on the
benefits and use of data for planning and x x x
decision-making in the targeted areas.

Activity
5.2

Assess the health data transfer performance of
the CSBs on a central level in order to identify
bottlenecks

Activity
5.3

Carry out regular follow-up and supervisory
reviews of the CSBs

x x x x x x x x x x x

x

Activity

Support coaching in the targeted areas

x x x x x x x x x x x

x

x

x

x

5.4

Annex 4: Process Indicators

Indicato Numer Denomi
Source
r
ator
nator

Basel
Baseli
Object
Objec
ine Source ne
ive
tive
value
date
date

Strength
en
the
provision
of
quality
Objec
health
tive 1
services
to
the
entire
populati
on
Contract
healthPercenta
Planned
care
Contracts
ge
of Numbe number
workers
signed and
health- r
of of
Activi in
the
registered by
care
workers workers
0
ty 1.1 marginali
the partner
workers contract to
be
zed
service and
contracte ed
contracte
health
the DDDS
d
d
care
facilities

n/a

50
physic
ians
and
2007 100 2010
midwi
ves
and or
nurses

Identify
the
factors
(geograp Existence
of
an
hical,
assessme
financial
Activi and
nt
and
n/a
ty 1.2 cultural) protocol
that limit report on
the use of piloting
strategies
the
services
through
field

n/a

n/a

n/a

Report
supplied by n/a
the DDDS

n/a

2008

Indicato Numer Denomi
Source
r
ator
nator

Basel
Baseli
Object
Objec
ine Source ne
ive
tive
value
date
date

research
Pilot
strategies
in around
5 SSDs
aimed at Identifica
increasin tion
of
g the use strategies
of
the that have
Activi services contribut
n/a
ty 1.3 based on ed to an
the
increase
results of in the use
the
of
the
assessme services
nt study
(see
activity
1.2)

n/a

Carry out
renovatio
ns
(painting,
purchase
of
furniture
for
receiving
patients,
roofing, Percenta
ceiling ge
of
etc.) 15 CSBs
Numbe
Activi CSBs per renovate
r
of 45
ty 1.4 year with d from
CSBs
the aim the
of
planned
improvin 45
g
their
physical
appearan
ce
and
making
them
more
welcomin
g
to
patients.

Report
supplied by n/a
the DDDS

n/a

n/a

n/a

2009

Written
receipt
of
the
works
and
the
works
assessment 0
reports,
obtained
from
the
DRSPF and
the DDDS

n/a

2007 45

2010

Indicato Numer Denomi
Source
r
ator
nator

Basel
Baseli
Object
Objec
ine Source ne
ive
tive
value
date
date

Head-up
PTA
ratificatio
n
missions:
the
central
team of
the
Numbe
ministry Percenta
r
of
and
ge of the
PTAs 133 (111 Ratification
partners PTA
ratified districts mission
Activi will
be ratified
before +
22 report
– 79%
ty 1.5 deployed before
the year regions) DGS/DDS
in
the the year
end
per year and regions
regions end each
each
and will year
year
ratify the
PTA in
the field,
instead of
having
the PTA
sent
to
them
centrally.

Mission
2008,
report.
2007 100% 2009,
DGS/D
2010
DDS

Equip 10
SSDs
Numbe
with
a
Percenta r
of
Acknowledg
4x4
ge
of CSBs
ement
vehicle,
SSDs and and
132 (10 receipts and
the center
CSBs
CSBs SSD + 2 invoices
Activi superviso
equipped equippe centers supplied by 0
ty 1.6 rs with 2
with 4x4s d with and 120 the
vehicles
and
4x4s CSB)
coordination
and 120
motor
and
team of HSS
CSBs
bikes
motor
activities
with
bikes
motor
bikes

DGS/D
2007 100% 2008
DDS

Usage
Percenta Numbe
of 132 (10 reports and
ge
of r
SSDs and SSDs SSD + 2 maintenance
and
fuel 0
CSBs
centers and
CSBs and 120 invoices
with
submitted by
functiona with
CSB)
the
l vehicles functio
nal
supervising

DGS/D
2009,
2007 100%
DDS
2010

Indicato Numer Denomi
Source
r
ator
nator
vehicle
s

Introduce
different
strategies
for
increasin
g
the Identifica
populatio tion
of
n’s
strategies
financial that have
Activi accessibil contribut
n/a
ty 1.7 ity
to ed to an
health- increase
care
in access
services to
in
5 funding
SSDs:
Mutual
health
organizati
on system

Basel
Baseli
Object
Objec
ine Source ne
ive
tive
value
date
date

physician
and the head
physician of
the CSB

n/a

Report
supplied by
n/a
the
DGS/DDDS

n/a

n/a

n/a

2010

Improve
human
resources
Objectiv
managem
e2
ent of the
health
sector
Contracts
signed and
Number Planned
registered
Contractin Percentag
of
number of by
the
Activity g
e
of
workers workers to partner
0
2.1
activities workers
contract be
service
(see 1.1) contracted
ed
contracted and
the
DGS/DD
DS
Increase
the
Objectiv mobilizati
e3
on
and
allocation
of

n/a

50
physic
ians
and
2007 100 2010
midwi
ves
and or
nurses

Indicato Numer Denomi
Source
r
ator
nator

Basel
Baseli
Object
Objec
ine Source ne
ive
tive
value
date
date

financial
resources
Offer
training
on
financial
and
Training
programm
Number
Percentag
report.
er
of
Total
Activity
e
of
Attendanc
managem
manage number of
0
3.1
managers
e
sheet.
ent to the
rs
managers
trained
DGS/DD
managers
trained
DS
on
the
periphery
of
the
targeted
districts
Strengthe
n
the
applicatio
n of the
Equity
Funds and
mutual
Existence
health
of
a
organizati
strengthen
Activity on system
ing plan
3.2
implemen
for
the
tation
equity
plan in the
funds
targeted
health
care
facilities
(see also
activity
4.5)

DGS/D
2007 100% 2008
DDS

DGS/DD
DS

Carry out Percentag
Audit
financial e of health Number
reports
auditing care
supplied
of
facilities
Total
and
by
the
health
Activity supervisio that have
number of EMAR
care
0
3.3
n of the undergone facilitie health care (regional
facilities manageme
priority an audit s
and
healthnt team)
audited
monitorin
care
and
the
activities g
DGS/DD

DGS/D
2002 100% 2010
DDS

Indicato Numer Denomi
Source
r
ator
nator
with the
PEV
as
top
priority
(focused
on
the
continuati
on
of
child and
maternal
care) in
the
targeted
areas and
develop
corrective
strategies
for
improving
the
programm
er
managem
ent.

Basel
Baseli
Object
Objec
ine Source ne
ive
tive
value
date
date

DS

List
of
corrective
strategies
on
a
national
scale

Analysis
and
consolidat
ion of the
audit
reports by
the
DGS/DDS

Implemen
tation
guide of
the
corrective
strategies

2010

2010

Stimulate
demand
Objectiv
and use of
e4
the health
services
of
Activity Carry out List
a regional NGOs and
4.1
mapping associatio

DGS/DD
DS

2008

Indicato Numer Denomi
Source
r
ator
nator

Basel
Baseli
Object
Objec
ine Source ne
ive
tive
value
date
date

of
the ns
NGOs
working at
and
a
associatio communit
ns
y level in
working each
at
a region
communit
y level
Convene
Number
3
Percentag of
meetings
e
of authorit
per year
meetings ies in
Activity with 160
held
in which 3 160
4.2
local
each local meeting
authorities
authority s have
in
the
per year been
targeted
held
areas.

Meeting
minutes
supplied
by SSD

C
onvene
meetings
for
drafting
policy
documents
establishin
Existence
g
of
a
Activity communit
communit
4.3
y health
y health
strategies
policy
(including
Reference
Terms and
a
Minimum
Activity
Package
(PMA))

DGS/DDD
S

0

2008,
2007 100% 2009,
2010

2008

Annex5: Allocation per Year (US$)

Allocation per year (US$)
GAVI
Allocation

HSS

Birth cohort
Allocation
newborn

per

Annual allocation

Q4
of
implementat
ion

Year 2 of
implementat
ion

Year 3 of
implementat
ion

Year 4 of
implementati
on

2007

2008

2009

2010

655 882

674 247

693 126

712 533

$5

$5

$5

$5

819,852.5

3 371 235

3 465 630

3 562 665

TOTAL
FUNDS

11 219 382,5

COST PER YEAR PER CATEGORY – Calculated in
USD in 2006
(costs based on the unit costs as per annex 5)
Explanatory notes

Sal Per Tra Lod Sup Hire Da Sur Pub Eq
arie die nsp gin plie of ta vey lica uip
s ms ort g s teac an s tion me
and
hing aly
s/di nt
rate
equi sis
sse
s
pme an
min
nt d
atio
and use
ns
roo
m,
prin
ting
expe
nses

Veh Fue Ren Tot
icle l ova alpur and tion 200
cha mai
7
se nte
nan
ce
for
veh
icle
s

Tot
al200
8

Activit processes + salaries up
y 1.1 to 2010

Tot
al201
0

466, 512,
274 901

385
50 physicians and 100 350
midwives
and
or
nurses
Activit National consultant: 8
y 1.2 weeks; International
consultant:: 5 weeks (2 292 280 100 420
trips x 2 weeks: 5000 00 0 56 0
per air ticket + per
diem); Data + survey

Tot
al200
9

423,
885

10 100
500
00 000

162,
532

COST PER YEAR PER CATEGORY – Calculated in
USD in 2006
(costs based on the unit costs as per annex 5)
Explanatory notes

Sal Per Tra Lod Sup Hire Da Sur Pub Eq
arie die nsp gin plie of ta vey lica uip
s ms ort g s teac an s tion me
and
hing aly
s/di nt
rate
equi sis
sse
s
pme an
min
nt d
atio
and use
ns
roo
m,
prin
ting
expe
nses

Veh Fue Ren Tot
icle l ova alpur and tion 200
cha mai
7
se nte
nan
ce
for
veh
icle
s

Tot
al200
8

Tot
al200
9

Tot
al201
0

analysis and use
Activit National consultant: 4
y 1.3 weeks per SSD=15
weeks. Transport of 470
CSD coaches to the 00
SSBs.
International
consultant: 6 weeks
Activit 3 monitoring and
y 1.4 supervision visits per
CSB = renovation of
15 CSBs per year
Activit 7 days and 6 nights per
y 1.5 region (22), 2 people
per region

79,1
49
300
0

900

60

250 10
0
00

500

60,
000
per
CS
B

112
675
50

76,4 84,1
69,5
72 19
20

616 500 693
110
0 00 0

Activit The cost also includes
y 1.6 the maintenance and
fuel costs for the
duration of the project

135
825
000
00
0

Activit Same estimation as for
y 1.7 1.3, multiplied by 1.5

1,10 1,21
1,00 4,51 4,97
4,10 8 0
8

1,00 120,
916, 8,23 788
575 3
158,
298

Activit Already budgeted in
y 2.1 activity 1.1
Activit 2 training sessions of 1
y 3.1 week each. 2 people
per region (44 people)
and 2 people per
district (230) = 274
trained. 2 trainers per

264 128 322
822 600
36 800 05

276,
514

COST PER YEAR PER CATEGORY – Calculated in
USD in 2006
(costs based on the unit costs as per annex 5)
Explanatory notes

Sal Per Tra Lod Sup Hire Da Sur Pub Eq
arie die nsp gin plie of ta vey lica uip
s ms ort g s teac an s tion me
and
hing aly
s/di nt
rate
equi sis
sse
s
pme an
min
nt d
atio
and use
ns
roo
m,
prin
ting
expe
nses

Veh Fue Ren Tot
icle l ova alpur and tion 200
cha mai
7
se nte
nan
ce
for
veh
icle
s

Tot
al200
8

Tot
al200
9

Tot
al201
0

province and 2 training
sessions per province.
Drivers = 1 per region
(22) and 100 per
district
Activit Same as activity 4.5
y 3.2
Activit 1 week per year per
y 3.3 CSB 40 SSDs and 15
CSBs = 400 CSBs. 2
technicians,
1
administrator and 1
chauffeur per CSB

1,11 1,22
5,49 7,04
1,01
4 4
4,08
6

826
147 600
840
87.
000 000
0
5

National consultant for
3 weeks for drafting 345
the corrective strategy 0
list at a national level.

5,05
1

Activit 1 national consultant,
y 4.1 1.5 weeks per region. 531
The cost includes 30
transport and lodging
Activit 15 people per meeting
y 4.2 per local authority.
Duration
of
the
meetings = 1 day.
District people go
down
to
the
communities.
40
districts are targeted.

500
.00

64,8
92
190, 209,
027 030

179 960 216 720
70 00 00 0

172,
752

COST PER YEAR PER CATEGORY – Calculated in
USD in 2006
(costs based on the unit costs as per annex 5)
Explanatory notes

Sal Per Tra Lod Sup Hire Da Sur Pub Eq
arie die nsp gin plie of ta vey lica uip
s ms ort g s teac an s tion me
and
hing aly
s/di nt
rate
equi sis
sse
s
pme an
min
nt d
atio
and use
ns
roo
m,
prin
ting
expe
nses

Activit Consultation
for
y 4.3 drafting = 1 month. 2
workshops
(presentation
and
460 196 440 132
ratification) and 2 days
480 240
0 8 00 0
with 40 people (1
person per region)
Who
attends
the
meetings?
Activit 40 workshops (2.5
y 4.4 days) at the SSDs. 30
people per SSD.

500
.00

Veh Fue Ren Tot
icle l ova alpur and tion 200
cha mai
7
se nte
nan
ce
for
veh
icle
s

Tot
al200
8

Activit 400 CSBs (1 person
y 5.1 per CSB) + 40 districts
(1 person per district)
= 640 trained. 2
trainers (1 regional and
1
central)
per
workshop,
12
workshops of 23 days 345 244 646 301 192 2,16
0 08 000 50 0 0.00
each

Tot
al201
0

19,4 47,1
73 24

241,
017

228 720 270 120 400
80 0 00 000 0

Activit National consultant for 184
y 4.5 4 months
00

Tot
al200
9

500
.00

22,8
69
1,03
6,71
2

Consultant
for
preparing the training
(curriculum)
=
3
weeks
Preparation
meeting
(team
building)
Activit Use the same data as

27,6

COST PER YEAR PER CATEGORY – Calculated in
USD in 2006
(costs based on the unit costs as per annex 5)
Explanatory notes

Sal Per Tra Lod Sup Hire Da Sur Pub Eq
arie die nsp gin plie of ta vey lica uip
s ms ort g s teac an s tion me
and
hing aly
s/di nt
rate
equi sis
sse
s
pme an
min
nt d
atio
and use
ns
roo
m,
prin
ting
expe
nses

Veh Fue Ren Tot
icle l ova alpur and tion 200
cha mai
7
se nte
nan
ce
for
veh
icle
s

Tot
al200
8

y 5.2 for equity funds

=

Tot
al201
0

71

Activit 2 days x quarter x SSD
y 5.3 (40) –
600 head
physicians of the CSBs
go to the SSD,
therefore
1
head
physician per CSB
6 dollars
journey

Tot
al200
9

143, 158,
748 123
576 144 360
00 00 00

130,
680

return

Activit Coaching visits. 10
y 5.4 regions. 40 districts.
Each SSD is visited 4
times per year for 3
days. 2 coaches per
SSD.

92,8 102,
51 136
153 400 144
60 00 00

84,4
10

Note: Training of the
coaches covered by the
World Bank
Procurement of IT
material
(including
ink, disks etc.) for 40
SSDs

170
00

Includes coordinating
and
supervision
missions
in
the 147 300 600 225 169
districts (2 per year x 00 0 0 0 30
40 districts) and in the
regions (2 per year x
10 regions) 2 days per

560
00

22,6 24,8
80,3 20,5 27 90
00 70

25, 50,
105
050 000
05
.00 .00

710 781
55.4 60.9
972 645 35 785
35.8 95.8
75 5

COST PER YEAR PER CATEGORY – Calculated in
USD in 2006
(costs based on the unit costs as per annex 5)
Explanatory notes

Sal Per Tra Lod Sup Hire Da Sur Pub Eq
arie die nsp gin plie of ta vey lica uip
s ms ort g s teac an s tion me
and
hing aly
s/di nt
rate
equi sis
sse
s
pme an
min
nt d
atio
and use
ns
roo
m,
prin
ting
expe
nses

Veh Fue Ren Tot
icle l ova alpur and tion 200
cha mai
7
se nte
nan
ce
for
veh
icle
s

Tot
al200
8

Tot
al200
9

Tot
al201
0

mission
Twice a year 20 people

200 40

120 120

240 528

580. 638.
8 88

Annex 6 List of Cost Used

2007
Objectiv Strengthen the provision of
e1
quality health services to the 0.0
entire population

2008

2009

2010

Total

1
988 2
549 2
505 7
043
013,3
787,7
940,1
741,2

Objectiv Improve
human
resources Contracting already budgeted for in
e2
management of the health sector activity 1.1
Objectiv Increase the mobilisation and 276
e3
allocation of financial resources 514,3

472 335,6 519 569,2

576
577,2

Objectiv Stimulate demand and use of the 241
e4
health services
017,5

263 948,4 120 548,7

132 603
758 118,1
5

Objectiv Strengthen and institutionalize a
195
e5
monitoring
and
evaluation
507,9
system

619 524,1 185 355,8

255
329,1

1,844
996,3

1
255
716,9

Cost of
the
Management costs
support
TOTAL

97 475,9 65 123,9
810
515,5

71 636,2

78 799,9 313 035,8

3
408 3
446 3
549 11
215
945,3
897,6
249,8
608,4