The World Bank/WBI’s CBNRM Initiative

Case Received: January 31, 1998

Author: Nat Quansah

Tel: +261 20 22 421 44

Email: quansah@bow.dts.mg

Integrated Health Care for Conservation Programme -- The Case of a Community Using Local Medicinal Plants to Help Meet Their Health, Economic and Biocultural Diversity Conservation Needs in Madagascar

The Integrated Health Care for Conservation Programme (IHCCP) is a programme that is based on the Integrated Health Care System. This is a system that consciously targets and harnesses peoples' links with (knowledge of and dependence on) biodiversity (especially, medicinal plants) for health reasons as a positive tool and combines the resources (human and material) of the traditional and modern medical systems to arrive at meeting the health and economic needs of people while conserving the biological and cultural (biocultural) diversity of the area all at the same time (Quansah, 1994; 1996).

The programme is based in Antananarivo, the capital of Madagascar, and Ambodisakoana Village (located about 1000km from Antananarivo) in the western part of the Manongarivo Special Reserve area, northwest Madagascar.

The west and southwestern parts of Manongarivo, the area covered by the programme has about 16 villages and a population estimate of around 3,000 people. The main ethnic group is the Tsimihety, with Sakalava and Antakarana ethnic groups also being present.

This area has the Manongarivo Special Reserve (MSR) which forms part of the Sambirano vegetational zone, a zone with marked endemism and regarded to be among the richest in biodiversity in Madagascar (Guillaumet, 1984; Raxworthy, 1988; Raharimalala, 1991). Covering both humid evergreen and moist semi-deciduous forests, the MSR depicts an excellent example of a lowland Malagasy rainforest gradually rising to become a montane forest, with its altitudinal range of about 50m to 1876m.

Strong links exist between the people of this area and the other elements of biodiversity around them. The links are expressed in the communities' knowledge of and dependence on the local biological resources of the area for their livelihood, as for example, for food, fuel, medicine, shelter, and transport (Quansah, 1988; 1991; 1993; Andrianarisata, 1994; Miadana, 1996).

The Programme enabling community members to have access to the use of local medicinal plants in a sustainable manner and complemented with pharmaceutical products to meet their health needs would have a positive socio-economic impact. In effect, the programme's approach means community members manage their own effective and affordable health service resulting in improved health for all; increased awareness of the importance of medicinal plants as 'life-savers' and thus, give them a reason to take up their responsibility to save medicinal plants and their habitats as well as the use-traditions that go with these plants.

The author is the creator and facilitator of the programme. Having, carried out botanical, ethnobotanical, ethnomedical, environmental, and biodiversity conservation training and research programmes in Madagascar, since 1985 to date; seen the difficult living conditions and poverty experienced by the Malagasy, not least, those in the rural areas and observed the continuing loss of the rich biocultural diversity of the Country; the author conceived the Integrated Health Care System approach to help arrive at meeting the health, economic and biocultural diversity conservation needs of people and their areas all at the same time.

This case presentation is about the pilot Integrated Health Care for Conservation Programme (IHCCP), started in 1992 in the Manongarivo area, in Madagascar.

Like any other community, the people of the Manongarivo area have many concerns. The three principal ones were: the poor state of their road which is immotorable for almost 9 months of the year, resulting in high prices for commodities brought in and difficulty in transporting agricultural produce out; the local agricultural system of slash-and-burn rotation which threatens the loss of forest cover; and the inadequate health services, resulting in the poor health conditions of the people. These concerns which the community had made known to the Malagasy authorities and other visitors that had gone to the area, were expressed during discussions that had taken place when the author and his team of trainee researchers had visited the Manongarivo area to carry out ethnobotanical research, first in 1988 and subsequently in 1989 through to 1992.

Health, however, was the most important of all these community concerns. The nearest hospital was 80km away, with a third of the journey having to be made on foot. Medicines at this hospital, if available, were very expensive and often beyond the patients ability to purchase. This meant that people had to rely on local traditional medicine (based mainly on the use of medicinal plants) for meeting their primary health care needs. This, however, was not enough to satisfy the diverse health needs of the community.

Added to this was the disappearing rich biodiversity of the area and the local knowledge that go with them (especially, medicinal plants and their local use-traditions), due to habitat loss, loss in confidence in the local remedies as a result of the belittling of the local traditions and the awaiting of the promise of alternative modern medical remedies by outsiders (local and foreign) who happen to visit the area; and the non-sustainable means of using these resources (Quansah, 1991; 1993; 1994).

All the people of the area but mostly the women and children as well as the local biocultural diversity would be the primary sufferers; however, other Malagasies and the rest of the world community would also suffer if the problem went unaddressed.

Good health is a primary requisite for any people to be able to carry out effective and successful activities on their own and/or in partnership with others, in their area. It is when people are healthy and have had something to fill their stomachs that they will listen to revitalised and/or new ideas and also be able to perform at maximum capacities and in an efficient manner.

Frequent meetings between community elders and/or members and the author and his team of trainees during which community concerns, the local environment and research and training

activities being carried out in the area by the author were discussed, led to the realisation of the IHCCP in the area. In late 1992, during one of the general meetings, the community decided to construct a health centre in one of their villages, since health was their number one concern. They, then, asked the author to help find funds to equip the centre, as that was beyond their reach. This was how the IHCCP was concretised in the Manongarivo area.

To be able to contribute to the reduction (and possible elimination) of sufferings caused by poverty and ignorance by improving the health and economic well-beings of people as well as saving the biocultural diversity of their area is what spurred me on to help initiate this change through the creation of this programme.

There is now a Clinic at Ambodisakoana Village built by the community with local materials and labour at the end of 1992. This was after the elders selection of Ambodisakoana as the site for the Clinic had been approved by community members. Funds from the Grants Management Unit (GMU) of the USAID in 1993 helped to initially equip the Clinic. Additional funds from the Fonds national suisse (FNS), World Wide Fund for Nature (WWF) - International and the International Development Research Centre (IDRC) - Canada, led to the acquisition of more equipment and to take care of the running costs of the Programme from 1994 till mid-1997.

The Integrated Health Care Clinic started functioning formally from mid-January 1994. In the Clinic, the local traditional healer works with a medical doctor and a local assistant using medicinal plants and pharmaceutical products for the prevention and/or treatment of diseases.

This work in the Clinic is enhanced by the provision of information on the authentication, standardisation and research leading to sustainable use of selected medicinal plants for diseases like asthma, diarrhoea, fever and wounds, by the IHCCP's laboratory wing based at the 'Laboratoire de pharmacologie générale et de pharmacocinétique' at the University of Antananarivo. This aspect of the Programme has resulted in increase in ethnobotanical, ethnomedical and ethnopharmacological research interests at the University of Antananarivo.

The management of the Clinic is carried out by a Local Health Committee (made up of elected representatives of the various villages) and the Clinic personnel, with support from the Village Council and the author.

The free prescription of medicinal plants and the proximity of the Clinic have made it possible for community members to save funds and be able to purchase the pharmaceutical products prescribed for diseases that cannot be treated with local medicinal plants. For example, the use of a local medicinal plant for asthma results in a patient saving about US$20. Similarly, using local medicinal plants for the treatment of scabies has meant a saving of US$15 by patients.

The proximity of the Clinic has also meant that transportation, feeding and lodging as well as high hospital costs which used to be incurred by patients and those who had to accompany them to the hospital some 80km away, have been eliminated. Thus, adding to the funds saved by community members.

As health costs are usually borne by the whole family, the saved amount enables the family to pay for health costs of other family members. The saved amounts also enable the family to pay for other expenses relating to, for example, a child's education and the family's nutrition.

The traditional healer working with the medical doctor in the Clinic as well as the use of local medicinal plants and pharmaceutical products in disease prevention and/or treatment has led to the increase in community members' perception of the need to use their resources in a sustainable manner. It has also resulted in the revitalisation of the tradition of using medicinal plants in the area, and triggered off a favourable response to the call for the need to save local biocultural diversity. The evidence of this is the community not cultivating an area of about 2km stretch of forest in the south-southwestern part of Manongarivo earmarked for cultivation. The reason given been that 'it contains medicinal plants that are helping to save our lives.'

The need for effective communication at all levels and times. Open and frank discussions among those involved in the programme, help to create the right environment for the functioning of the programme. Misunderstandings are reduced (eliminated) with trust and confidence being built up, thus, helping to boost up morale. When morale is high, people tend to contribute their part more willingly and effectively.

Full community participation is essential. There are different user groups when it comes to using resources. Within these are lay persons and specialists. Involve all of them as each one can contribute to finding solutions to the problems of resource use in their area.

The need to search for, acknowledge and respect the diversity in people's capabilities, especially, at local community levels. Effort must be made to look for, acknowledge and respect the different capabilities of people. This leads to easy targetting and maximizing of resources and contributions from the community. People's creative abilities are also developed as a result of this, making them want to contribute in a more positive way.

The importance of appreciating people's efforts. The appreciation of one's effort and commending them on jobs well done (no matter how small) serves as a motivating factor and makes them want to try harder and contribute better for the success of the programme.

Capacity reinforcement must be done at both technical and resource levels at the same time. Reinforcing ones' capacity through the provision of tecnical know-how is important but is not enough on its own. This must go hand in hand with reinforcing the material, equipment and/or infrastructural capacity of the area. This is the surest way to have a long-lasting durable and effective change. The presence of a capable, hardworking people with appropriate resources to carry out their activities is a key to the success of any programme.

Patience, adaptability, open-mindedness and time are important requirements for success. Patience, the ability to adapt and open-mindedness must be the hallmark of all those involved in a programme. With this, it becomes possible to learn from each other, understand and be able to accommodate the pace at which each one does things and try to modify accordingly. Enough time must be devoted to and allowed for the programme. Make haste slowly and be prepared to look at things in an objective manner and in the real life context.