Madagascar's health system

Photo: mother and sick child with healthcare worker

The organization of Madagascar’s healthcare system reflects the administrative structure of the country.  

It is structured around four distinct operational levels: 

  • The Central Level, made up of the directorates and central services of the Ministry of Public Health, defines the overall direction of national health policy and the main strategic focuses and priorities. 
  • The Regional Level coordinates the implementation of national policy in the 22 regions of the country and in every respective health district. 
  • The District Level is the local level. The key drivers are the 114 health districts, which oversee all control activities at hospitals and primary health centres (PHCs). These health care facilities deliver promotional, preventive and curative services. 

The Community Level is the foundation of the system. There is a network of community workers supported by health committees, health care facilities, and international and national nongovernmental organizations (NGOs). 

Health care is organized into three tiers: 

  • The first tier, at health district level, comprises: (i) provision of services in the community, through community workers and health staff using an outreach approach; (ii) primary health care facilities, which serve as the user’s entry point into the health care system or Level 1 and 2 PHCs and offer the minimum package of activities (MPA). 
  • The second tier comprises the district referral hospitals (CHRDs) without surgery, which provide the complementary package of activities, and the CHRDs with surgery representing frontline or first-level referral hospitals. 
  • The third tier comprises the regional referral hospitals and university hospitals (CHUs); these are the second- level referral hospitals. 

Alongside these three levels of provision, case management of uncomplicated malaria in children aged under 5 years is handled by community facilities, where there are two community workers per fokontany (smallest administrative subdivision in Madagascar). The objective was to recruit 39 812 community workers in 19 906 localities to cover all needs for uncomplicated malaria for all age groups. Severe cases are treated at the referral hospitals. Private-sector health care providers and facilities provide the same services as PHCs and hospitals, offering a fee-paying service. 

Private sector 

The private sector is represented by private medical providers and centres (company or faith-based, NGOs, doctors' surgeries, etc.), the private pharmaceutical sector (wholesalers, pharmacies, drug depots) and private companies.  

These entities play an important role in the healthcare system as they serve a significant proportion of Madagascar population, mostly among the urban population. There are preventive and curative services for malaria control, although these can be geographically limited. Supplies remain limited and are still not easily accessible to the poorest populations. 

In 2019, 528 centers/providers were identified and received training/information under the grants; they share data on management of fever and malaria. These providers apply the national protocol for management of malaria. Reporting remains a major challenge for these private medical providers, given that only a small proportion (36% of the 528 centers) submit a monthly activity report to the Ministry of Public Health.