Physiotherapy in Madagascar
Madagascar is ranked as the ninth poorest country in the world and has a population of 25.5 million people. Most people in Madagascar live in poverty with 78% of the population living on less than US$1.90 per day. For this large population number, there are only 300 Physiotherapists in the whole country. Physiotherapists are trained at the University of Antananarivo, the Capital City in Madagascar, however training is theoretical based and provided by medical physicians with limited to no experience of physiotherapy. From March until May 2019, I travelled to Madagascar to work as a Voluntary Physiotherapist in different hospitals throughout the country.
I have always had a passion for supporting the development of healthcare services in Low-and Middle-Income Countries (LMIC’s). As a student at the University of Birmingham, I travelled to Tanzania where I completed a one-month placement in a school for disabled children. After graduating, I completed 3.5 years of Band 5 rotations at the Leeds Teaching Hospitals Trust (LTHT), gaining invaluable skills in a wide range of rotations. During this time, I began to make contact and develop links with other therapists who have spent time working in LMIC’s through ADAPT, and Global Rehabilitation.
Global Rehabilitation are a Charity based within LTHT which aims to support the development of Rehabilitation services in Madagascar. Projects the Charity have supported include; developing a rehabilitation speciality for medical doctors, providing training and supporting an amputee rehab service, and developing the first spinal cord injury rehab centre in Madagascar. The Charity work in collaboration with Malagasy staff to publish papers and research documenting their work, which also helps to incorporate the importance of research into the healthcare system in Madagascar.
After getting in contact with Global Rehabilitation, I then started preparing to travel to and work in Madagascar. I self-funded my work through cake sales, a raffle, and a gofundme page. In March 2019, I took a career break from LTHT and set off for Madagascar!
Healthcare Systems in Madagascar
In the year prior to Madagascar, I spent a lot of time contacting Malagasy physiotherapists, meeting with other healthcare staff who had worked in Madagascar before, and attempting to gain an understanding of what my work would involve. But that’s where my plans stopped. Having never worked or visited the country before, I had no idea of what to expect, both in terms of where I would be living and working. I therefore, did not plan training or an agenda before arrival, as I did not want to make plans based on my assumptions of what the healthcare system would be like.
For the first few weeks I simply observed the physiotherapists and doctors, in an attempt to gain an understanding of how they work. I recorded daily observations, making note of everything from treatment spaces used, type of injuries and patients seen, choice of treatment methods and analysis, and how patients were referred to therapy. I then decided to conduct interviews and questionnaires with all physiotherapists and doctors to gain a more detailed understanding of the physiotherapy service in Madagascar.
The healthcare system in Madagascar was completely different to anything I had experienced before. Physiotherapy is not an autonomous profession, and physiotherapists actually study nursing initially and then choose physiotherapy as a separate branch of nursing to study. The training to become a physiotherapist is taught by doctors, who teach a ‘recipe’ style approach to treating patients. For example, “if you are treating a patient who has suffered from a stroke, you must treat them by following steps A, B, C.” The fact that each patient is an individual and will present with different symptoms is not taught as part of the Physiotherapy curriculum in Madagascar. Physiotherapists do not write notes and do not clinically reason through treatments. Instead, a doctor prescribes what they would like the physiotherapist to do, and this usually consists of massage as treatment. This is often common practice in many LMIC’s.
I also met with the Ministry of Health in Madagascar, and the University staff who teach Physiotherapy. I conducted interviews with them and explained that I hoped to gather as much information as possible from a wide range of sources in order to support the development of Physiotherapy services in Madagascar in future.
Last but not least, I became involved in an amputee rehab training programme and a spinal cord injury rehab programme during my time in Madagascar. Both projects were delivered with the support of healthcare professionals from the UK in association with the Charity Global Rehabilitation. The spinal cord injury training was delivered to local physiotherapists, nurses, neurosurgeons, and midwives, and was supporting the development of the second Spinal injury rehabilitation centre in Madagascar. My role involved delivering training on functional outcomes post spinal cord injury, positioning to prevent pressure sores, chest management, the assisted cough technique, and how to complete a log roll.
Returning to the UK
Since returning to the UK, I have been writing up the findings of my observations, interviews and questionnaires into a report. This report is currently under peer review for publication. I hope that by publishing a report based on the physiotherapy service in Madagascar, it will support the development of Physiotherapy services in future which are specific to the local population and the healthcare staff in Madagascar.
I have also started two new jobs in Leeds, one working as a Band 6 Physiotherapist at LTHT, supporting the development of a new spinal service, and one working at the University of Leeds as a Research Physiotherapist in Spinal Cord Injuries. I feel that it is my experiences in Madagascar that allowed me to gain these two new roles, and I hope to continue to work in spinal services both in the UK and in LMIC’s for years to come.
If you would like to support the ongoing development of healthcare and rehabilitation in Madagascar, you can donate through Global Rehabilitation’s website: https://www.globalrehabilitation.org/donate