ANTANANARIVO, 30 May 2011 (IRIN) - Hospital patients in Madagascar are used to paying for everything from surgeon's gloves and gauze to drips and syringes, but a protracted political and economic crisis has further weakened the public health sector and put cancer treatment out of reach for all but the lucky few.

Currently, just one cancer ward with 60 beds at the Joseph Ravoahangy Andrianavalona Hospital (HJRA) in the capital Antananarivo, is serving the entire population of nearly 20 million, and treatment there is well beyond the means of the majority of Malagasy, nearly 70 percent of whom live below the poverty line.

The March 2009 coup in which Andry Rajoelina, with the support of the military, deposed President Marc Ravalomanana, led to the suspension of numerous foreign aid and trade benefits on which the country was heavily reliant, particularly for the funding of social sectors. According to the UN Children's Fund (UNICEF), the government has also significantly reduced its spending on health just as the economic crisis has depleted many families' ability to pay for health care. 

"The majority of people here can't pay [for treatment]; they are farmers, or unemployed," said Melanie Anton, a child psychologist at HJRA.

A state fund which is supposed to provide free drugs and medical supplies for those unable to pay for health care covers a fraction of the need, according to social workers at HJRA, and patients' fears of running up medical bills they cannot afford means many abandon treatment early, or never seek it in the first place.

"Parents are worried about not being able to pay for medicines, so they pull their kids out of hospital before treatment or surgery is completed and take them back home," Anton confirmed.

The problem is particularly common for cancer treatment, with medicine prices on the rise and chemotherapy sessions costing up to two million ariary (US$1,000), according to HRJA's head of oncology, Florine Rafaramino.

Costly trips to the capital

Rafaramino said patients often lost precious time and money travelling to the capital. "It's catastrophic for them, especially those who come from the countryside. People come and sometimes just leave again as their money has gone," she told IRIN.

The parents of three-year-old Marosia travelled over 500km to bring their daughter to HJRA after doctors in their home region of Sava failed to diagnose her stomach pain as a tumour.

"Before coming here, we went round a lot of hospitals and everyone told us to come here," said her father Teddy Tombotam, who works in the vanilla trade.

His wife has given up work to be with Marosia while Tombotam returns to Antananarivo every 15 days to spend a couple of days with his daughter. Despite being significantly better off than the majority of Malagasys, getting treatment for their daughter has been financially crippling.

"It's difficult for a small trader but what can I do? It's my daughter, my only daughter," said Tombotam, adding that if Marosia needed more than the estimated three chemotherapy treatments "we'll be bankrupt".

Broken equipment

Even making it to the capital in time and having the means to pay for treatment does not guarantee it. Medicine stock-outs are common and the hospital's one radiotherapy machine, which is needed to treat 8 percent of cancer cases, has been broken for over a year.

"We have one machine for over 20 million people that doesn't work," said Rafaramino, who noted that the World Health Organization recommends a minimum of one radiotherapy machine per one million inhabitants.

While several charities provide funding to cover the costs of treating certain cancers and age groups, staff are unable to help those patients who do not tick the right boxes and cannot meet costs themselves.

"The guilt is awful if you see a child die," said Rafaramino, adding that many patients died in discomfort at their homes.

NGO plans new clinics

Some of the difficulties in accessing cancer treatment may be alleviated by the plans of local charity, 4aWOMAN, to set up three new cancer clinics in Antananarivo, in Madagascar's second biggest city Fianarantsoa to the south, and in the city of Mahajunga in the northwest.

4aWOMAN, a project of the Akbaraly Foundation set up by Cinzia Akbaraly, the wife of one of Madagascar's most successful businessmen, targets breast and gynaecological cancers which account for 52 percent of cancer cases in Madagascar.

Project Manager Jacques Schmitt said funding for the clinics would cover the cost of radiotherapy machines and staff training, but that a culture that prevents many women from getting screened for such cancers also needed to be tackled.

"The problem of culture means that many women, especially in rural areas where there is a lack of awareness or stigma about gynaecological examinations, don't get diagnosed," he told IRIN. "That means that often we're dealing with diagnoses where death is almost certain."

Source: The Integrated Regional Information Networks (http://www.irinnews.org )