partner impact madagascarMadagascar, the fourth largest island in the world, is also one of the world's poorest countries. 80% of the population lives in rural areas with difficult access to most services. In Madagascar, as in many other countries, the remote communities living in poverty are the most vulnerable segment of society. The availability of health services is extremely limited, leading to high rates of infant, child, and maternal mortality. In addition, 65% of the population does not have access to safe drinking water and sanitation.

The USAID-funded Madagascar Community-Based Integrated Health Project, known locally as MAHEFA, is focused on providing basic, quality health care to isolated populations in six north and northwestern regions of Madagascar (DIANA, SAVA, Sofia, Menabe, Boeny and Melaky).

"Since my days in the military, my vocation has always been to serve people. I've transported more than 70 people with my bicycle ambulance - children, pregnant women, and the elderly," 65 year old Robin Erinesy, ETS driver. "I like knowing that even at my age, I can still make a difference in my community. This work allows me to save lives and also keeps me physically fit."

Malagasy Health Care


Focus on women and children

To reduce maternal and neonatal deaths, timely access to skilled care before, during, and after pregnancy is critical. Delays in accessing quality care are a key contributor to maternal and neonatal mortality. Inadequate access to transport is one of the three main delays in accessing health services.

Through MAHEFA, over 5,000 community health workers (CHWs) in the target areas are trained, equipped and supported to provide services in all of MAHEFA’s intervention areas. The increase in quality services at the community level will result in reduction of neonatal and child health morbidity and mortality.

Community Health Volunteers (CHV)

 Zondia Helena Nirisoa Photographer Robin Hammond for the JSIMAHEFA Program, USAIDMadagascar

"Having a bicycle allows us to increase the amount of work we can do. When we didn't have bicycles we could visit eight people, now that we have them we are able to visit 18."

Community health volunteers (CHV) play a vital role in providing health services in Madagascar, especially in remote regions where government health services may be limited. CHVs provide antenatal care, deliver vaccines, teach about proper nutrition and sanitation practices, among other family planning services. CHVs who reside in rural areas must often travel long distances to conduct health activities and provide services to families who rely on them. The considerable time and financial burden on CHVs limits the quality of services that CHVs are able to provide.

Solution: MAHEFA provided 1,020 bicycles to CHVs in 220 communities. Find out what happened when CHVs received bikes...

Emergency Transport Scheme (ETS)

Photo Robin Hammond/Panos

"I do it to help my community"

To reduce maternal and neonatal deaths, timely access to skilled care before, during, and after pregnancy is critical. Delays in accessing quality care are a key contributor to maternal and neonatal mortality. There are multiple challenges that influence availability and use of transport in rural Madagascar. Transport availability is often low; and when transport is available, cost is often a major barrier. Moreover, in MAHEFA regions, the mountainous and sandy terrain is challenging to access by motor vehicle and the majority of sites experience reduced access during the rainy season.

Solution: MAHEFA introduced a range of locally appropriate non-motorized modes of transport including stretchers, bicycle ambulances, canoes, and ox-drawn carts. Find out more about the ETS solution...

eBox- Micro- Finance Enterprise


"The eBox motivates the CHVs in their community health work. It encourages the CHVs to work even in the lean season when people don't have money," Mayor of Miandriavazo.

Though CHVs in Madagascar are a recognized cadre in the government health system and serve as a critical element to the national community health strategy, they do not receive a salary from the government. Given the minimal rewards that exist for CHVs, methods to increase income generating opportunities are critical for providing incentives and retaining CHVs to continue the important work they do.

Solution: MAHEFA implemented the eBox approach to respond to gaps in the bicycle sales and repair market as well as to provide new skills and income generating opportunities for community members. Profits from the eBox project also help fund the ETS and community mutuelle, the same insurance policy that helped save Tokiniaimpireneko during her pregnancy. Read more about the eBox solution AND the BfW supported co-op Miandrivazo.


 Health Care Beneficiaries and Providers

Tokiniaimpireneko Floubertinhna Elimir Photographer Robin Hammond for the JSIMAHEFA Program, USAIDMadagascar

Tokiniaimpireneko was transported to a health facility when she fell ill during her pregnancy. The community based health insurance helped pay for her care and her trip to the hospital in the bike ambulance. She is seen here with her healthy baby girl.


Faralahy is a CHV that treats children. "I note significant changes have taken place here since we started providing counseling on health. For example, fewer children under the age of five are dying. Our people used to be affected by various diseases, but today the situation has improved."


Angelette is a Community Health Volunteer. She provides care to mothers and their babies particularly newborns and those under five years old. "I monitor child growth every month by weighing them. I provide counseling to pregnant women and I refer them to the local health centers."

robin headshot

Robin drives a bicycle ambulance in his community. Ten years ago Robin was very sick and called the hospital for an ambulance. They refused to send help. After flagging down a passing car the family was able to make their way to the hospital. "They demanded a lot of money to help someone who was very sick," said Robin of the car who stopped to help and charged the family $9 for the ride. Robin wanted to help save lives and make a difference in his community.


Baby Mahazomaro almost died when he was only 18 days old. Mahazomaro's parents (mom above) gave up hope when the local clinic said they weren't equipped to treat his respiratory distress. Robin Erinesy, his ETS driver, immediately loaded Mahazomaro into his bicycle ambulance and transported him to the hospital where they were able to treat his illness and save his life.

Mr Frederick Photographer Robin Hammond for the JSIMAHEFA Program, USAIDMadagascar

Frederic is the president of his local health committee and transport service. He is also a trained mechanic working in the community eBox initiative. Frederic ensures that the CHV bicycles and ETS bike ambulances are working properly and have the necessary spare parts when they are in need of service.