We Did It Ourselves: How Localized Efforts Have Transformed Family Planning Services in Madagascar’s Highland Regions

The Accessible Continuum of Care and Essential Services Sustained (ACCESS) Program, funded by the US Agency for International Development (USAID) and implemented by Management Sciences for Health (MSH), has a core mission to reduce maternal and infant mortality in Madagascar by providing consistent, quality health services across 14 regions. In Vakinankaratra, Amoron’i Mania, and Haute Matsiatra, the focus has been on family planning.

In Madagascar, family planning faces significant cultural and logistical challenges.

Many communities still regard discussions about contraception as taboo, and the traditional beliefs of some individuals and/or their spouses may make them reluctant to use birth control. Moreover, families living in remote and hard-to-reach areas may not have access to transportation services or the financial means to utilize them, which can make obtaining family planning products and services difficult.

Community health workers play a crucial role in dismantling these taboos and bringing care closer to the patient while still handling each situation with sensitivity and respect. With support from the USAID ACCESS program, health workers conduct awareness campaigns, home visits, and community education sessions to help foster a safe and comfortable environment so families can have these important conversations and seek the reproductive and preventive care they need.

As a result, the three highland regions of Vakinankaratra, Amoron’i Mania, and Haute Matsiatra gained 693,000 new family planning users between 2019 and 2023. Contraceptive coverage rates increased across all three regions—most notably in Haute Matsiatra, where the rate went from 24% in 2019 to 53% in 2023.

Two community health volunteers pose for a picture with Dr. Vololoniaina Rasoanandrasana, Head of Family Planning, Ministry of Public Health, during the event to celebrate achievements made over the past six years. Photo credit: MSH

Strengthening Health Workforce Capacity

Through capacity building and the introduction of new tools, health centers in Vakinankaratra, Amoron’i Mania, and Haute Matsiatra are now able to offer more robust family planning services.

ACCESS has supported Regional Health Directorates in strengthening the clinical skills of more than 450 health workers and 1,800 community workers over the past six years. To ensure these skills can be sustained and adapted to create lasting impact, regular follow-ups, supervision, and continuous mentoring were included in the capacity building strategy. This not only improves the quality of family planning services but promotes the proper management and use of innovative tools and resources.

“In our community, we talk about [these services] not only for family planning but for thriving—for ensuring the well-being of each household and every woman.” — Fara, a community worker in the Lalangina district. Fara has seen a shift in attitudes thanks to the use of participatory approaches and home visits aimed at convincing sometimes reluctant spouses that it is alright to use contraceptives. Just four years ago, her regular user base was about 15-20 people and has since grown to over a hundred. Photo credit: MSH

Through capacity building and the introduction of new tools, health centers in Vakinankaratra, Amoron’i Mania, and Haute Matsiatra are now able to offer more robust family planning services. 

ACCESS has supported Regional Health Directorates in strengthening the clinical skills of more than 450 health workers and 1,800 community workers over the past six years. To ensure these skills can be sustained and adapted to create lasting impact, regular follow-ups, supervision, and continuous mentoring were included in the capacity building strategy. This not only improves the quality of family planning services but promotes the proper management and use of innovative tools and resources.  

A health worker provides family planning services to a young couple. Photo credit: MSH

Strategic Interventions for Sustainable Impact

The progress made across Vakinankaratra, Amoron’i Mania, and Haute Matsiatra marks the beginning of a new chapter for family planning in the Malagasy Highlands. This six-year collaboration between USAID ACCESS, the MOPH, and local authorities demonstrates how a localized approach can ensure lasting change. With renewed commitment from the Regional Health Directorates to manage and build on these initiatives, the local health system will continue to ensure equitable access to quality family planning services. 

“To deliver quality services, change starts with oneself. Beyond the clinical skills training from the Ministry of Public Health (MOPH) and ACCESS, individual dedication and passion [for this work] are crucial for humane, quality care. Three pillars underpin appropriate services: material availability, staff competence, and the humanization of care.” — Fanjasoa Zakamanitriniaina, affectionately known as Fanja, who is a midwife and head of the Mandriankeniheny Health Center. Photo credit: MSH

Ensuring Continuity with the Ministry of Public Health

Although ACCESS’s work in these regions concluded in June 2024, the program left behind a strong community-led initiative and plan for continuing progress that is being implemented by and for the people it serves.  

At a ceremony in Fianarantsoa on June 20, Regional Public Health Directors shared their commitment to continuing these essential initiatives, marking a crucial transition to local management of family planning efforts.  

Related: Check out this video to learn more about Fanja’s story and how she is helping to transform health care in rural Madagascar. 

“We are proud to have contributed to these promising results and congratulate the Ministry of Public Health and local health workforce. They can proudly say: ‘We did it ourselves!'” — Dr. Serge Raharison, Program Director, USAID ACCESS. Photo credit: MSH