Stratégie Nationale sur la Couverture Santé Universelle

Objectives

Madagascar’s National Strategy for Universal Health Coverage provides a progressive, multisectoral pathway towards ensuring that all people can obtain quality health services without financial hardship, while being protected from health-related risks. It places equity and solidarity at the centre, with particular attention to people living in extreme poverty, disadvantaged groups and populations facing geographical, social, cultural or financial exclusion.[1][2][3][4]The strategy is aligned with national development, health-sector and social-protection priorities and aims to strengthen human capital, reduce health-related impoverishment and contribute to broader poverty reduction.[5][6][7]

• Protect individuals and families from catastrophic or impoverishing out-of-pocket expenditure through coherent financial-protection and prepayment mechanisms.[8][9][10]
• Improve the effective availability, accessibility, acceptability and quality of preventive, curative, rehabilitative, primary and hospital services, particularly in remote and underserved areas.[11][12][13]
• Reduce exposure to environmental, occupational, behavioural, epidemic, food-safety, sanitation, water and climate-related health risks.[14][15][16]
• Mobilise and coordinate public, private, partner and innovative financing for universal health coverage.[8][17][18]
• Strengthen population participation, transparency, user information, feedback and social accountability in health-system governance and service delivery.[4][19][20]
• Extend a minimum package of social and health protection to people experiencing extreme poverty, including outreach and integrated medico-social support where mainstream services are inaccessible.[9][21][22]

The intended model seeks to avoid a two-tier system in which poorer people receive inferior care. It combines financial protection with improvements in service readiness, health-worker availability and motivation, medicine affordability, referral systems, respectful patient reception and community participation.[23][24][25][26]It also recognises that existing free-care, exemption, mutual-insurance and subsidy mechanisms have limited and uneven reach, requiring better harmonisation and progressive expansion.[27][28][29]

Implementation

Implementation is designed as a long-term, adaptive whole-of-government process led by the Ministry of Public Health and coordinated with social protection, finance, planning, labour, population and decentralisation authorities.[3][7]It relies on collaboration among central and decentralised government, communes and regions, public and private providers, employers, insurers, mutual health organisations, civil society, communities, professional bodies, faith-based organisations and technical and financial partners.[30][31][32]

• Establish a national Steering Committee, chaired by the Prime Minister or President, to review implementation progress and constraints, issue recommendations and coordinate with social-protection monitoring arrangements.[31][32]
• Maintain an Operational Support Unit within the Ministry of Public Health to coordinate actors, support implementation, develop indicators, prepare consolidated action plans and budgets, disseminate information, coordinate training and facilitate external support.[33][34][32]
• Develop annual action plans that select feasible, visible and short-term cross-sectoral measures, particularly for health-risk prevention, local sanitation, awareness and regulation.[35][36]
• Strengthen district, regional and community-level delivery through health mapping, mobile and integrated services, maintenance of facilities and equipment, improved referral arrangements and engagement of decentralised local authorities.[37][13][38]
• Improve service quality through clinical protocols, supportive supervision, staff training and retention, results-based financing, patient-centred care, disciplinary measures and regulation of public, private and informal providers.[11][39][25][26]
• Expand beneficiary participation through consultation spaces, community structures, household surveys, accessible complaint mechanisms, Community Score Cards and qualitative indicators covering satisfaction, reception and responsiveness.[19][20]

A central delivery mechanism is the progressive establishment of an autonomous national health-insurance organisation, potentially operating as a Health Insurance Fund and ultimately serving as the single national insurance mechanism.[10][40]Coverage would combine compulsory affiliation for public-sector and formal-sector workers, voluntary participation for others outside the formal sector, and publicly or partner-financed affiliation for vulnerable people.[2][40][41]Existing inter-company health organisations would be integrated rapidly, while mutual health organisations would join progressively and could retain complementary-insurance or delegated-management roles.[40]The insurance mechanism would define covered primary and hospital services, negotiate tariffs and provider contracts, establish payment arrangements, validate claims and manage financial risk.[41][42][12]

Financial protection would progressively reduce direct user charges by combining State budget support, insurance prepayment, possible co-payments, redirected free-care resources, conditional cash transfers, vouchers and innovative financing.[30][10][41]A dedicated universal health coverage fund, governed by a multipartite board, would collect relevant resources, finance affiliation for identified poor people and retain a strategic-purchasing role in relation to the insurer.[42]Potential innovative sources include earmarked taxes on mobile communications, money transfers, tobacco, alcohol, sugary drinks, pollution and other harmful products, alongside corporate contributions, sponsorship and locally assigned tax revenue.[2][17][18]The source cautions that such taxation should not undermine household resources or economic development.[2][18]

Monitoring arrangements include Madagascar-specific and internationally recognised universal health coverage indicators, with particular attention to equity, progress reports prepared by the Operational Support Unit and Steering Committee review at least twice yearly.[34][32]A consolidated annual universal health coverage budget would bring together relevant expenditure by the State, insurers, local authorities and other actors, support assessment of the national effort, and enable ministerial and parliamentary scrutiny through the Finance Bill.[17][31][34]The supplied material does not specify numerical financing requirements, contribution rates, a complete indicator set, reporting templates or detailed evaluation methods.[31][34][32]

Monitoring & Evaluation

Monitoring and accountability are centred on an Operational Support Unit within the Ministry of Public Health and a national Steering Committee chaired at high political level. The unit is to coordinate implementation, develop indicators, support evaluation, prepare progress reporting and remain accountable to the committee; the committee is to meet at least twice yearly to review progress, implementation difficulties and recommendations.[34][32]

• Develop Madagascar-specific and internationally recognised Universal Health Coverage indicators, drawing on the World Health Organization and World Bank monitoring framework and giving particular attention to equity.[34]
• Review implementation through progress reports prepared by the Operational Support Unit, consolidated action plans, and periodic review of strategic orientations as implementation advances.[9][32][43]
• Use the dedicated Universal Health Coverage budget to monitor implementation, assess the overall cost of Universal Health Coverage and measure the national financing effort, alongside monitoring of budget execution across institutions.[17]
• Coordinate monitoring with mechanisms under the National Social Protection Policy and evaluate activities undertaken under the Universal Health Coverage strategy.[34][32]
• Strengthen social accountability through qualitative facility indicators on user satisfaction, reception, consideration of beneficiaries’ views, consultation, and participatory monitoring and evaluation.[19][20]
• Collect, process and periodically use beneficiary complaints and needs; improve feedback boxes, household surveys, standardised facility assessments and Community Score Cards, and provide feedback to communities.[19][20]
• Monitor provider and staff accountability through claims validation and insurance risk management, tariff oversight, inspection, standards enforcement, disciplinary procedures and quality competitions for health facilities.[12][38][26]
• Track selected service and protection mechanisms through existing evidence, including mutual membership, employer-based affiliation, equity-fund reach and service-use results from conditional cash transfers.[28][29][44]

Available baseline evidence includes health-status, disease, service-coverage, water and sanitation, service-readiness, and disaster-impact statistics.[45][14][46]The extracts do not provide a complete indicator list, indicator definitions, reporting templates, surveillance architecture, evaluation methodology, quantified targets, or a detailed formal accountability framework beyond the institutional, budgetary, quality-control and feedback mechanisms described.[17][34][32]

Costing & Financing

The financing model combines progressively expanded public funding, prepayment and insurance, redirected free-care financing, technical and financial partner support, and innovative earmarked revenue. It seeks to reduce direct payment at the point of care, which is identified as a barrier to access and a source of catastrophic household expenditure and impoverishment.[47][10][41]

• Prepare an annual consolidated Universal Health Coverage budget covering relevant State expenditure and spending by other actors, including insurers and local authorities, and integrate the dedicated budget into the Finance Bill for ministerial and parliamentary scrutiny.[17][34]
• Increase and release State health funding efficiently, retain a substantial State role in facility operating budgets in the short term, and prioritise provider budgets and service quality as health spending rises.[10][12]
• Establish a national health-insurance mechanism funded through compulsory coverage for public and formal-sector workers, voluntary coverage outside those groups, and subsidised affiliation for vulnerable people.[40][41]
• Create a dedicated fund with multipartite governance to collect and strategically purchase affiliation using redirected free-care resources, conditional cash transfers, vouchers and innovative financing; reserve part of its resources for risk reduction and people living in extreme poverty.[42][48]
• Mobilise potential earmarked taxes on mobile communications, money transfers, tobacco, alcohol, sugary drinks, pollution and other health-harming goods, while assessing feasibility and avoiding tax levels that could harm economic development.[2][17][18]
• Coordinate corporate social-financing contributions, sponsorship of insurance contributions by individuals, institutions or diaspora associations, local tax revenue, partner support, and direct financing of activities.[2][18][31]
• Consider co-payments at basic health centres and hospitals after insurance coverage, while limiting direct payment after prepayment mechanisms are introduced to any applicable user co-payment.[30][31]

Health mutuals and other contributory mechanisms are financially fragile because of low enrolment, limited risk pooling and dependence on donor support during establishment; people in poverty may be unable to afford premiums.[28]The extracts provide no overall monetary budget, allocation, contribution rate, unit cost, quantified funding gap, expenditure forecast or economic assumptions for implementation.[40][17][34]