Health in Madagascar

The Ministère de la Santé Publique (MSP) leads the national health system. Regional services are coordinated by the Direction Régionale de la Santé Publique (DRSP), while the Service de District de la Santé Publique (SDSP) works at district level. Public and private providers operate alongside community services. The usual sequence begins with Agents communautaires and community sites in Fokontany communities, followed by a Centre de Santé de Base CSB1 or CSB2. A CSB1 generally provides basic services through paramedical staff, while a CSB2 has medical staff. A Centre Hospitalier de Référence de District (CHRD) provides general medicine, general surgery, obstetrics and emergency care. A Centre Hospitalier de Référence Régionale (CHRR) adds specialist services and more advanced emergency care. A Centre Hospitalier Universitaire (CHU) provides national-level highly specialized care, university training and research. People may also seek private care directly. Referral capacity, geography and transport can limit access between these levels. Community and primary-care programs include routine and campaign vaccination, antenatal and postnatal care, family planning, vitamin A, deworming, screening for acute malnutrition, malaria prevention with insecticide-treated nets, health promotion, and prevention or surveillance for tuberculosis, HIV and neglected tropical diseases. Community workers mobilize households, report symptoms, maintain vaccination registers and follow people who have missed scheduled services. CSB teams and community workers may use mobile or outreach services at community sites, especially in remote areas more than 5 km from a facility. CHRD facilities have an emergency-care mandate, with CHRR and CHU facilities serving higher referral levels. Madagascar does not have a reliably verified, uniform nationwide emergency medical service accessible to everyone, and the CAMUM regulatory framework is still developing. An old COVID-19 hotline should not be treated as a general emergency number. Practical emergency capacity varies between facilities. After discharge or referral, follow-up depends on the facility and program. Community workers can support treatment adherence, household follow-up, vaccination catch-up and tracing of people lost to follow-up. Antenatal and postnatal continuation is available through relevant services, while long-term follow-up for chronic diseases is uneven. Mental-health care remains fragmented: psychiatric services are concentrated mainly in larger cities, and selected districts or regions use community networks and WHO mhGAP-based approaches. A formal nationwide mental-health pathway and established long-term-care system have not been confirmed. The Agence du Médicament de Madagascar (AGMED) and the Direction de la Pharmacie, des Laboratoires et de la Médecine Traditionnelle (DPLMT) regulate medicines. A marketed medicine requires an Autorisation de Mise sur le Marché (AMM). AGMED publishes authorized and withdrawn medicines and authorized pharmaceutical establishments. A pharmacist may propose a lower-cost generic, but the prescriber’s agreement is required. Salama handles medicines procurement at national level, while stocks and availability vary between facilities. Traditional medicine has a formal registration process through AGMED and DPLMT, but traditional self-medication also occurs. It does not automatically provide an equivalent diagnosis or treatment. Severe symptoms or warning signs require assessment at a CSB or hospital. The Charte du patient hospitalisé applies in public and private establishments. It recognizes free choice of practitioner or facility subject to technical capacity, organization, tariffs, third-party-payment rules, geography and transport. Patients have rights to information, free and informed consent, refusal of care, privacy, medical confidentiality and access to their medical record. Facility charters also define patient duties. Public primary care is intended for the population as a whole, but individual programs can set eligibility conditions. Routine immunization is publicly supported, while targeted voucher schemes for children under five and pregnant or postpartum women operate only in beneficiary regions. Fees, medicine costs, transport and waiting times vary, and the essential primary-care package under universal health coverage is still being put into operation. No single nationwide tariff or waiting-time table has been reliably verified.