The Fabulous Fabienne

One nurse-midwife’s journey to establishing a community-led health care facility with improved services in Madagascar

Marie Fabienne Edourdine, known fondly as Fabienne, proudly led visitors into Manamby Centre Santé de Base (CSB), or Basic Health Center in English, in her Madagascar community. When Fabienne started at the CSB more than seven years ago, the facility was in very poor condition with an unreliable water supply and inadequate toilets. That’s why the manicured garden and bright shrubs that now greet visitors bring so much meaning.

Before Fabienne’s arrival, there was only one traditional pit latrine that both staff and patients shared. There was no piped water in the facility, not even in the labor and delivery room, and no fencing to mark the health center’s property lines.

“I didn’t even recognize that it was a CSB,” Fabienne said. “Now people come here to take pictures of the facility.”

In Madagascar, roughly 2,600 CSBs are classified as either Level 1 or Level 2, depending on the size of population they serve. CSB1s are staffed by a trained paramedic or nurse. CSB2s, often located in bigger villages or regional centers, are typically staffed by a medical doctor, and have beds and rooms for patients.

Since 2018, the USAID-funded ACCESS Program has supported more than 1,800 CSBs throughout the country. This has resulted in the construction and rehabilitation of 100 drinking water points and 180 hygienic toilets in 107 health care facilities, the training of 418 health workers and the establishment of 162 hygiene committees.

In 2021, the Manamby CSB where Fabienne works was certified by the Ministry of Health and Madagascar’s Ministry of Water and Sanitation as a “WASH-Friendly” facility. This means the facility has piped water, sanitary toilets, handwashing facilities for health care staff and patients and waste management facilities. In addition, health staff have been trained on infection prevention control, and there is an established Hygiene Committee.

As a requirement of an investment by ACCESS, the community was expected to contribute roughly $280 to the total $5,000 cost of improvements to the facility.

Through local advocacy efforts, Fabienne, her husband, and other local health staff mobilized their community to contribute a small financial contribution along with in-kind donations, which spurred community ownership and pride in the health facility.

That was just the start of Fabienne’s mission to transform the health center.

Another requirement of a WASH-Friendly facility is the formation of a Hygiene Committee composed of government officials, CSB staff, and community members. Their role is to keep the facility clean and develop annual work plans to specify the role and responsibilities of each member.

By design, the Hygiene Committee is part of the CSB, a government entity that is legally prohibited from fundraising. Under Fabienne’s leadership, the Hygiene Committee underwent a legal process to become what is now known as a Hygiene Association, an independent entity with its own bank account and ability to raise funds.

The association consists of 12 members, including a president (Fabienne), secretary, treasurer, and community members, such as the village chief, community health volunteers, and clinic staff. Each member contributes 2,000 ariary per month (less than $1 USD) and members can access the common fund should they or their family need to pay for services or medicine from the CSB. The association’s efforts have also provided new waste bins, lights, and a flag for the facility.

Fabienne said that having a formal association keeps the sanitation facilities clean and operational. While the commune pays for a cleaner, the association charges non-patients a small fee to use the latrines and showers, money it uses for cleaning supplies and facility maintenance.

The road to becoming certified was not easy, but Fabienne’s steadfast commitment has made the facility a model for the district. She said the secret to her success has always been community.

“I’m not a boss, but [I] involve the community,” said Fabienne. “I may not be here tomorrow so this is [theirs].”

Fabienne’s husband, who’s not a part of the CSB staff, helped to mobilize community funds and promote healthier behaviors. Fabienne acknowledges that without her husband’s support, it would have been hard to reach the current status of cleanliness and regular payment for use of the sanitation facilities.

This initiative demonstrates a successful adaptation to the challenging situation of WASH in HCF in Madagascar, and highlights the importance of adequately managing WASH facilities to ensure they are inviting and safe places to go for services. Access to water and sanitation and hygienic practices are key to infection prevention control.

Globally, infections are among the third most common cause of death for mothers and among one of the top four contributors to newborn death. Sustained access also protects health care workers and patients, enabling continuous, quality care even in the face of climate-related shocks like droughts, floods, and other natural disasters.

This is important, given that Madagascar is also the fourth most climate change-affected country in the world and impacted by frequent and intense droughts and cyclones, particularly in the south and southeastern part of the country.

This effort to improve primary health care, along with other WASH initiatives, are part of USAID’s investments in Madagascar, which is a High-Priority Country for the U.S. government.