Plan Stratégique National de Lutte Antitabac à Madagascar

Objectives

Madagascar’s National Strategic Plan for Tobacco Control for 2019–2024 is the national reference framework for accelerating implementation of the World Health Organization Framework Convention on Tobacco Control, contributing to the Sustainable Development Goals, and protecting present and future generations from the health, social, environmental and economic harms of tobacco use and exposure to tobacco smoke.[1][2][3]Its vision is a tobacco-free Madagascar in which everyone can live longer and in good health.[4]The plan seeks to reduce tobacco consumption, second-hand-smoke exposure and the wider burden on households, health services, productivity, the environment and livelihoods.[5][6][4]

• Reduce tobacco-use prevalence by 5% among adults and young people aged 13–15 by the end of the plan period.[4][7]
• Reduce exposure to second-hand smoke, with a target reduction of 1% per year from baselines of 62.9% among young people and 49.5% in homes.[8]
• Strengthen the institutional and legal framework through multisectoral coordination, legislation, enforcement, regional structures, advocacy, partnerships and protection against tobacco-industry interference.[4][9][8]
• Mobilise sustainable financing through an investment model, revised tobacco-tax legislation, regular tax reassessment and allocation of a share of tobacco-tax revenue to tobacco control and universal health coverage.[9][10][11]
• Protect people from tobacco smoke by strengthening and enforcing smoke-free rules in public places and workplaces, where compliance has been weak in educational institutions, government offices and hospitality venues.[12][13][14]
• Improve tobacco-product regulation through testing and disclosure systems, stronger and rotating health warnings, plain packaging, controls on advertising and promotion, and product tracking and tracing.[13][15][16][17]
• Expand prevention, communication and cessation support, including a national communication plan, public education, a toll-free information and counselling service, trained health workers, priority-district cessation services and a national cessation and tobacco-control information centre.[18][17][19]
• Address tobacco cultivation through mapping growing areas, studying growers’ income and health risks, and assessing alternative crops and income-generating activities that reduce deforestation, soil depletion, pesticide exposure and other environmental harms.[20][21][19]
• Strengthen research, surveillance, information exchange and international reporting on tobacco use and implementation of the Framework Convention.[21][22]

Implementation

Implementation is designed as a multisectoral, decentralised programme led by the Ministry of Public Health through the National Office for Tobacco Control, known as OFNALAT, working with the National Tobacco Control Consultative Committee, known as CCOLAT, government sectors, civil society, non-governmental organisations, professional groups, health facilities, Parliament, development partners and community actors.[1][4][7]The plan combines legal reform, fiscal measures, enforcement, health-service delivery, communication, research and regional coordination, while recognising that inadequate resources and incomplete operational mechanisms have constrained existing tobacco-control bodies.[12][23][16]

• Coordinate national action through OFNALAT and CCOLAT, and establish or operationalise regional tobacco-control focal points, regional coordination committees and consultative structures.[4][9][24]
• Assign complementary roles across sectors, including health for technical leadership, training, health education and cessation; finance for taxation, revenue information and anti-smuggling action; and other ministries for agriculture, trade, environment, communication, law enforcement, diplomacy and education.[22][25]
• Develop, disseminate and enforce tobacco-control legislation and regulations; monitor their application; record violations; and establish measures against illicit trade, advertising breaches and industry interference.[9][16][26]
• Implement Article 8 smoke-free protections by updating regulations, training responsible entities, conducting quarterly enforcement operations and strengthening compliance monitoring.[14][11]
• Implement packaging and labelling measures by revising Article 11 regulations, increasing health warnings from eight to sixteen, rotating warnings, and developing plain-packaging rules.[14][17][11]
• Deliver cessation support by assessing existing provision, developing a national guide or protocol, establishing a freephone counselling service, training and equipping health workers, and creating a national cessation centre.[18][17][19]
• Use communication and advocacy to launch the strategy, inform decision-makers and partners, promote tobacco-control measures, mobilise resources and support integration of tobacco control into the finance law.[27][3]
• Monitor progress against defined targets, including functional regional committees, notices restricting sales to or by minors, cessation-centre consultations, partnership platforms, legal instruments, enforcement entities and warning rotations.[8][26][28]
• Establish a tobacco-use surveillance system, support implementation research, document experience, exchange information nationally and internationally, and complete international reporting.[21][22][28]
• Resource priority activities through budgeted implementation lines, including regional coordination, legal monitoring, enforcement, communication, cessation and surveillance; the extracts identify allocations in Malagasy ariary for many activities but do not specify a total plan budget or funding gap.[24][16][17][22]

Monitoring & Evaluation

The plan combines outcome targets, implementation indicators, compliance monitoring, surveillance and international reporting to assess tobacco-control progress. Its monitoring and evaluation framework is intended to establish whether activities are advancing as planned, objectives are being met and implementation is achieving effects.[7]

• Measure progress towards reducing tobacco-use prevalence by 5% among people aged 13–15 and adults, with the plan presenting a 2023 target in its monitoring framework and a 2024 target elsewhere in the strategic objectives.[4][7]
• Track exposure to second-hand smoke from a baseline of 62.9% among young people and 49.5% at home, with a planned reduction of 1% per year.[8]
• Monitor enforcement concerning tobacco sales by or to minors, including increasing municipalities displaying prohibition notices from zero to 12 and applying sanctions such as product confiscation, destruction and temporary outlet closure for non-compliance.[15][8]
• Increase consultations at the national smoking-cessation centre from zero to 400, alongside development of cessation services, a guide or protocol, a counselling helpline and a national cessation and information centre.[18][17][8]
• Track institutional implementation through indicators for functional regional coordinating committees, committee meetings, advocacy meetings and a multisectoral partnership platform.[8]
• Establish systems to monitor application of tobacco-control legislation, trace tobacco products, record violations, assess Article 8 smoke-free protections and monitor Article 11 packaging and labelling requirements.[9][16][26][11]
• Conduct quarterly enforcement operations for smoke-free provisions and address reported weak compliance in education settings, public offices and hospitality venues.[12][13][14]
• Rotate and update health warnings, which had remained unchanged since 2012 despite an expectation of revision every two years, and evaluate the impact of packaging and labelling measures.[13][10][18]
• Develop tobacco-use surveillance, research and information exchange, including research on Convention implementation, tobacco cultivation, alternative livelihoods and international tobacco-control reporting.[21][19][22]
• Report internationally on tobacco-control achievements and disseminate completed reports, with the National Office for Tobacco Control responsible for surveillance and reporting activities in the implementation framework.[21][22]

The framework identifies substantial evidence and accountability gaps: earlier assessments found inadequate epidemiological surveillance, insufficient evaluation of prevalence-reduction interventions and limited research resources.[23]The supplied material does not provide a complete reporting timetable, common indicator definitions, data-collection protocols, evaluation methodology or wider formal accountability process.[4][9][16][14]

Costing & Financing

Financing is framed around tobacco taxation, investment-model advocacy and activity-level budget allocations, but the supplied material does not provide a consolidated total plan budget, expenditure execution arrangements, quantified funding gap or economic assumptions.[10][16][14]

• Mobilise additional tobacco-control resources through investment-model advocacy, engagement with government and Parliament, and incorporation of tobacco control into the finance law.[10][26][3]
• Revise tobacco-tax legislation and reassess taxation regularly to reduce affordability and consumption, particularly among young people, while limiting substitution towards cheaper tobacco products.[9][10]
• Increase the share of tobacco-tax revenue allocated to tobacco-control programmes from a baseline of 0% to a target of 0.5%.[11]
• Recognise that a specific tax benefits TAFITA, LOVAKO and the National Office for Tobacco Control, while the assessment identified no excise duty and no clearly defined minimum ad valorem tax on tobacco products.[12]
• Address inadequate or absent funding for civil-society prevention activity, insufficient resources for the National Office for Tobacco Control and the Consultative Committee for Tobacco Control, and the absence of dedicated funding for enforcement of smoking bans.[20][12][13]
• Build on the Ministry of Public Health budget allocated for Convention implementation for more than three years, while addressing the lack of budget allocations from other expected implementing partners and limited use of multilateral financing opportunities.[23]
• Implement budgeted activities for coordination, legal development, enforcement, cessation, communications, alternative livelihoods, research, surveillance and international reporting.[24][16][17][19][22]

Tobacco’s estimated annual economic cost to Madagascar was 491 billion Malagasy ariary in 2017, comprising 25 billion Malagasy ariary in health expenditure and 466 billion Malagasy ariary in lost productive capacity; this was equivalent to 1.4% of gross domestic product.[29]Global tobacco consumption was estimated in 2016 to cost more than 1,400 billion US dollars annually, including 422 billion US dollars in healthcare costs and 1,000 billion US dollars in productivity losses.[30]