PluriElles: Enhancing healthcare access for women in rural Madagascar

The PluriElles project seeks to improve access to local healthcare, including sexual and reproductive health services, while strengthening the fight against pandemics in two rural regions of Madagascar. This initiative addresses concerns over a potential rise in HIV prevalence*, an increase in tuberculosis incidence*, a growing malaria-related mortality rate*, and cervical cancer becoming a major cause of death among women*. To achieve this, 25 midwives are being recruited to work in community birthing centers. At the same time, the project reinforces referral healthcare facilities and provides support to local communities in the areas where the midwives are stationed. Rina Rakotonaivo, PluriElles project manager at Santé Sud, discusses the project’s implementation and its impact in these highly vulnerable areas.

What is the context of the PluriElles project in Madagascar?

Rina Rakotonaivo: The PluriElles project aims to tackle pandemics and improve healthcare, and to promote sexual and reproductive health rights in rural Madagascar through an integrated and gender-responsive approach. It addresses a critical challenge—the inequality in healthcare access between rural and urban areas. Healthcare facilities are unevenly distributed, and health outcomes are heavily influenced by the proximity and availability of medical services. However, basic obstetric and family planning services are scarce in rural regions, where 80% of Madagascar’s population resides. Women are the most affected, often walking long distances to access healthcare. Consequently, maternal and infant mortality rates remain alarmingly high.

The country is also experiencing a resurgence of infectious diseases, with higher prevalence and incidence in rural areas. Many people lack information about these pandemics and are unaware of where to get tested. The same trend is observed with cervical cancer, which remains the second leading cause of cancer-related death among women in the country.

How is the PluriElles project being implemented?

Rina Rakotonaivo: PluriElles is being carried out in two regions of Madagascar, where 25 self-employed community midwives are supported. The goal is to enhance access to sexual and reproductive health services for both women and men, with special attention to young people, while also fighting pandemics and cervical cancer.

In the Analamanga region, located in the center of the island, 13 midwives have already established community birthing centers across three districts and are receiving skills training through the project. In the Diana region, in Ambanja district, at the northernmost part of Madagascar, 12 new midwives have just been recruited and will be supported in setting up their community birthing centers by the end of the first half of 2025. These recruitments follow a feasibility study to ensure that the selected locations are economically viable and that local communities can afford the services. The local population and authorities engaged in discussions have shown strong motivation and commitment to the project.

What type of care is provided in these community birthing centers?

Rina Rakotonaivo: These community birthing centers offer maternal and infant healthcare services. Women of reproductive age can undergo cervical cancer screening, while pregnant women receive prenatal monitoring up until childbirth. In Analamanga, where 13 midwives are now operating, there has been a notable rise in prenatal visits and an increase in births assisted by qualified healthcare personnel. Moreover, within these centers, infants can receive vaccinations and screenings for malnutrition, HIV/AIDS, and tuberculosis.

Midwives also receive training on adolescent and youth reproductive health, as well as gender-based violence awareness. Additionally, they undergo specialized training on key project areas, including prevention, screening, and management of pandemics and cervical cancer. We are also working to strengthen their connections with local communities. Other complementary activities include awareness-raising and informational campaigns, led by youth peer educators and community health workers, who work closely with the midwives. This collaboration helps facilitate discussions with young people on sexual and reproductive health and rights. Furthermore, in coordination with our partner, the MAD’AIDS network, we provide psychosocial support to people living with HIV.

What tangible results has the PluriElles project achieved?

Rina Rakotonaivo: These community birthing centers are an entry point in the healthcare system. Ensuring that women have access to nearby health services helps limit their need to travel, as many lack the financial or logistical means to go far from home. These centers serve as an additional layer within the healthcare structure, reinforcing the continuum of care through referral systems. The project also provides training sessions to enhance care quality in referral health centers.

PluriElles is committed to empowering women. In these community birthing centers, they receive medical care, education, and information, enabling them to make more informed decisions about their own health. This project is also empowering for healthcare providers. Madagascar faces a shortage of healthcare personnel, with qualified midwives unable to secure state employment due to funding constraints. Thanks to the project, these midwives can launch and sustain their independent practices, achieve financial independence, and use their skills to serve populations in need.

* ONUSIDA Madagascar  
* National strategic plan for TB (NSP TB) 2018-2022
* EDS 2021, INSTAT
* INSTAT 2021