Strengthening Leadership and Management for Sustainable Health Impacts

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Strong leadership, management, and governance (LMG) is necessary at every level of the health system to ensure the effective implementation of accessible, affordable, and high quality service provision across the continuum of care. LMG includes overseeing functions such as human resources management, supply chain and equipment management, quality assurance (both clinical and non-clinical components of quality), referral systems, community engagement, data collection and use, and target setting, among others. To further enhance the LMG skills of the public health sector in Madagascar, the Madagascar Ministry of Public Health (MOPH) implemented an LMG training for managers, particularly at the district level, in line with the Leadership Development Program Plus (LDP+) initiated by MSH, and adopted by the MOPH and implemented by the USAID ACCESS program.

The LDP+ is an experiential learning cycle that focuses on achieving measurable results through team-based approaches to problem solving. An LDP+ cycle consists of four three-day workshops, conducted over six to eight weeks per team institution (in this case, MOPH department, division, or district service). For example, through the LDP+, the Safe Motherhood Service of the Family Health Department (Direction de la Santé Familiale/ DSFa) was able to identify the root causes of low rates of skilled birth attendance (SBA) at health centers in four target districts (Manakara, Mananjary, and Vohipeno in Vatovavy Fitovinany, and Vavatenina in Analnjirofo): the lack of information on antenatal care (ANC) and SBA among the target populations, as well as the importance of attending four ANC visits. During the LDP+ workshops, the team was able to work together to identify priority actions to improve SBA in health centers within the two regions, including enhancing the skills of community health volunteers to promote the importance of ANC and SBA at a health center and supporting district health management teams to use data to continuously monitor the rates of SBA. The process has proven effective, as three districts in Vatovavy Fitovinany recorded increases in the number of women giving birth at a health center, ranging from 2% to 10% increases between December 2019 and August 2020; the district in Analanjirofo recorded a 6% increase during the same time period.

Since December 2019, all five departments of the DSFa have implemented the LDP+, with the support of the ACCESS program. In addition to the results noted by the Safe Motherhood Service, the LDP+ resulted in a 5.6% increase in the rate of contraceptive coverage in one district in Atsinanana over a nine-month period beginning in January, and 18 youth-friendly health centers were established in Betsiboka. 

“Our team is working much more efficiently after these LDP+ workshops. The approach made us think a lot and tested our abilities to find solutions together. With our limited resources, we were able to maximize our potential and achieve much more significant results.” — Dr. Lalhyss Randriamanantsaina, Nutrition Designer, from the DSFa  

The National Malaria Control Program (NMCP) also implemented the LDP+. The completeness and timeliness rates of monthly activity reports for the five priority malaria control regions (Alaotra Mangoro, Androy, Anosy, Atsimo Andrefana, Bongolava) have increased significantly. For instance, the timeliness rates ranged from 56% to 85% in the 5 regions in January 2020; and after an eight-month LDP+ cycle that ended in October 2020, the rates ranged from 87% to 98%. In addition, 20 districts did not experience any stock out of malaria commodities during the period from February to October 2020, thus optimizing the diagnosis and management of patients.

“In the beginning, we thought we would never have the necessary resources to reach our objectives. We had no idea how we were going to define realistic and achievable challenges. But by working together as a team, we were able to do so and make tangible progress.” — Dr. Voahangy Razanakotomalala, Care Manager at the NMCP 

The LDP+ approach, through strengthening the LMG capacities of health managers, resulted in the achievement of realistic and measurable results, as identified and defined by the different services and departments of the MOPH. These results ultimately contribute to the reduction of maternal and child morbidity and mortality in Madagascar. In addition, the LDP+ can enhance progress toward strengthening the health system of Madagascar through the optimization of existing resources at all levels of the MOPH and through the increased abilities of public health staff to lead and manage effective and efficient health services.