Welcome to the USAID-funded Health Policy Plus (HP+) project website.
Links to documents and external sites open in a new window.
Links to documents and external sites open in a new window.
Health Policy Plus Madagascar held its closing event in Antananarivo on July 1, 2022, attended by representatives from the National Institute of Public and Community Health (INSPC), the Ministry of Public Health, the Ministry of Economy and Finance, USAID Madagascar, and HP+ experts. Achievements noted were the passage of a rights-based reproductive health and family planning law, a Health Sector Development Plan (2020–2024), and a National Strategic Plan for Community Health (2010–2030). Panel discussions dealt with strategic frameworks for health, increasing domestic funding, and family planning. INSPC Director Pâquerette Hanitriniala Sahondranirina urged attendees to keep working on the country’s goals: “… this day signifies that we are still together and ready to work for the good cause of health and well-being of the Malagasy population, which is a guarantee of sustainable development of the country.” Read more in the HP+ news story.
Many health workers and patients are not aware of the rights guaranteed to them by Madagascar’s new reproductive health/family planning (RH/FP) law adopted in 2019, nor of the duties required of health workers regarding RH/FP care. To support broader dissemination, HP+ Madagascar worked with Madagascar’s Directorate of Family Health to develop a job aid highlighting health workers’ RH/FP rights and obligations, including excerpts of the law adapted into simpler language to aid comprehension. The intended impact of the job aids is twofold: (1) to enable health personnel to educate their patients on the RH/FP rights and benefits protected by the law, and (2) to remind health workers of their own rights and responsibilities as outlined in the law, as well as the penalties for neglecting their duties. The job aid will be disseminated throughout USAID’s 13 regions of intervention in Madagascar.
In Madagascar, HP+ has supported seven government ministries over the past several years as they committed to implementing the country’s Demographic Dividend Roadmap, demonstrating multisectoral support of efforts aimed at achieving the demographic dividend. The roadmap is centered around four pillars: health and family planning, education, employment, and governance. Under each pillar, the roadmap monitoring plan details key actions to take to attain the demographic dividend and indicators to measure progress throughout implementation. The plan serves as an implementation, monitoring, evaluation, and decision-making tool for stakeholders from the seven government ministries, private sector, civil society, and technical and financial partners to ensure the execution of the Demographic Dividend Roadmap in Madagascar.
Government stakeholders collaborated with HP+ to reduce the resource need gap and ensure efficient and needs-based resource prioritization for the health sector. Using the OneHealth Tool and other classification methodologies, stakeholders reached consensus on the essential health programs, interventions, and inputs for the strategic plan. Presenting key challenges, lessons learned, and recommendations for the future, this brief can be used to advocate for increasing domestic resources for Madagascar’s health system and to inform the Malagasy government, as well as a wider audience beyond Madagascar, about best practices and potential pitfalls with the financial planning process for a health sector strategic plan.
HP+ Madagascar has been supporting the Ministry of Public Health to draft a national health financing strategy to advance universal health coverage in the country. In December 2021, the ministry’s Secretary General led a workshop to validate the strategy with participants from technical and financial partners, civil society organizations, and the private sector. Throughout the strategy development process, HP+ supported staff to assess the country’s existing health financing mechanisms, develop national health financing goals, and define the strategy’s vision, objectives, and strategic axes. HP+ also played a role in supporting government partners to understand the purpose and importance of the strategy while facilitating dialogue between government actors, parliamentarians, donors, partners, and civil society representatives to ensure collective ownership of the strategy through a participatory, collaborative, and inclusive process. HP+ will now integrate stakeholder input into the strategy, coordinate finalization and dissemination, and support the development of an implementation plan and monitoring, evaluation, and governance frameworks.
At a roundtable event held on September 28, 2021, the president of the Republic of Madagascar, ministry officials, and technical and financial partners signed the country's official FP2030 commitment. HP+ supported the Ministry of Public Health to organize and facilitate the event to renew the country’s commitment to family planning, including a pledge to increase family planning resources. HP+ also supported efforts to define the country's objectives for 2030 and presented the economic incentives and investment case for family planning at the roundtable. The gathering brought together 200 participants, including senators, parliamentarians, government ministry officials, technical and financial partners, and leaders from civil society. The next step is for the Family Planning Committee, led by the Directorate of Family Health, to develop a 2022–2023 national costed implementation plan to achieve Madagascar’s FP2030 commitments through improved communication, domestic resource mobilization, service delivery and access, and monitoring and evaluation.
A significant policy win was achieved as HP+ Madagascar supported the development of the Public Financial Protection Law, which is intended to create a more favorable legal environment in support of universal health coverage. At a meeting with parliamentarians that HP+ helped organize in May 2021—a rare collaboration between the Ministry of Health and parliamentarians—the parliamentarians accepted the importance of the law and proposed to be part of the process of carrying it forward to advance equitable healthcare access. The president of the National Assembly’s Public Health Commission was particularly engaged and volunteered to personally carry forward the Public Financial Protection Law. The law includes the creation of a new National Health Solidarity Fund, which will be financed through direct transfers from the national budget, private donations, and external funding and will cover contributions for poor and vulnerable populations. Now that the parliament has bought in, they are developing both the law and the national strategy for health financing alongside partners such as the Ministry of Finance and Budget and Ministry of Decentralization. Next steps include establishing a coordination mechanism between the National Assembly and the Ministry of Health and conducting further advocacy in favor of increasing the state budget for the health sector.
Youth in Madagascar have provided valuable input during a review of Madagascar’s 2016–2020 Costed Implementation Plan (CIP) for Family Planning and provided insight to be considered for the next CIP. The participatory and multisectoral CIP review, for which HP+ provided technical support, included the perspectives of youth stakeholders as members of the family planning committee. Their insight was particularly valuable as Madagascar’s CIP addresses the unique needs of young people in a country where nearly 60 percent of the population are under the age of 25. The CIP review revealed that the modern contraceptive prevalence rate among young people increased by 4 percentage points from the CIP’s introduction in 2016 to its end in 2020. Furthermore, recommendations from a May 2021 virtual consultation, led by the Youth Advocacy Association as part of the CIP gap analysis, will be factored into the next CIP (2021–2025). Their proposals include improving contraceptive supply chains, continuing to strengthen implementation of the 2018 law on reproductive health and family planning, bolstering government commitment to family planning, and improving service offerings that meet the specific needs of young people. They requested specific strategies targeting youth and recommended greater engagement of youth networks, nongovernmental organizations, and associations in family planning demand creation.
Madagascar’s Ministry of Public Health has published a final review of its 2016-2020 Costed Implementation Plan (CIP) in a new report available through HP+. The CIP is a five-year roadmap that identifies evidence-based strategies and approaches for improving family planning programs and estimates the costs of implementing those strategies. The final review report examines and details the CIP achievements using Organisation for Economic Co-operation and Development (OECD) criteria of effectiveness, efficiency, coherence, relevance, impact, and sustainability. The effort was part of the project’s commitment to help strengthen Malagasy capacity to develop, implement, and monitor health sector policies and strategies to improve equity and sustainability of health services. Information from the review report, which also includes perspectives of family planning stakeholders in-country and a literature review, will be used by Madagascar stakeholders as they develop the country’s next CIP and to improve the nation’s family planning program. HP+ had previously supported the government of Madagascar’s efforts to develop and implement the national costed implementation plan (CIP) for family planning (2016-2020).
Madagascar’s Ministry of Public Health has finalized its final review of the 2016-2020 Costed Implementation Plan for Family Planning. HP+ provided updated gap analysis results and costed implementation plan (CIP) dashboard data, as well as a CIP execution checklist (part of the CIP Resource Kit). The final review report was validated in April by Madagascar’s Family Planning Committee, technical and financial partners, representatives from regional and district health directorates, civil society organizations, and youth networks. Key successes identified in the review include an increase in the modern contraceptive prevalence rate from 33 percent in 2012 to 41 percent in 2020, representing an estimated 959,000 more contraceptive users. Further, the political environment was improved through passage of the law regulating reproductive health and family planning, ensuring access to reproductive health and family planning services to vulnerable populations, youth, and individuals with disabilities without discrimination. HP+ contributed significant technical and financial support to the development of this law. The Madagascar Ministry of Public Health Family Health Directorate demonstrated strong country ownership and staff capacity throughout the final review process, including through its assessment and validation of all tools and materials used during the review.
With HP+ technical support, Madagascar’s Ministry of Public Health recently validated the Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition Investment Case for the Global Financing Facility. The investment case outlines priorities for interventions and regions in addressing the country’s RMNCAH-N objectives and health system improvements. HP+ was the lead technical partner, in collaboration with UNICEF, the United Nations Population Fund, the World Bank, and the World Health Organization, supporting the ministry in the development of the investment case. The process offered the opportunity to improve the alignment of donor financing with government priorities and objectives. It also focused on targeting limited government resources on high-impact practices and healthcare access for the country’s most vulnerable populations. HP+ will continue to provide technical assistance to build the ministry’s capacity to monitor the implementation of the investment case at national, regional, and district levels. The investment case aims to reduce the total fertility rate—the average number of births a woman has over a typical lifetime—from 4.6 to 4.2 and aims to reduce the adolescent fertility rate from 151 to less than 130 births per 1,000 women. The five-year plan would reach 17 out of 22 prioritized regions, covering 19.1 million people (78 percent of the population) and avert more than 9,000 neonatal deaths, approximately 3,000 maternal deaths, and nearly 40,000 deaths of children under five years of age.
HP+ is working to advance implementation of a transformative reproductive health and family planning law in Madagascar by providing advocacy training to representatives of civil society organizations and government ministries. Twenty-eight participants from 17 civil society organizations and government ministries—including youth and women's organizations and three ministries (health, youth, and population)—attended an HP+-hosted advocacy training from February 24–26, 2021. Using the Advance Family Planning SMART approach, participants developed work plans, budgets, and SMART objectives. Examples of objectives include incorporating a budget line for state participation in contraceptive purchasing and conducting a situational analysis and consultation with persons with disabilities regarding access to reproductive health and family planning services. During the next 12 months, HP+ will continue to provide support and monitor the SMART objectives and advocacy plans developed and adopted during the training.
In Madagascar, seven government ministries have signed an official commitment letter agreeing to implement the country’s Demographic Dividend Roadmap, demonstrating multisectoral support of efforts aimed at achieving the country’s demographic dividend. The commitments, obtained at a high-level roundtable organized by HP+ in March 2020, are the result of HP+ efforts to support Madagascar’s Ministry of Economy and Finance to finalize a follow-up plan for the roadmap, including details on monitoring and evaluation, budgeting, and resource mobilization for key activities. Moving forward, HP+ will support the demographic dividend team to advocate for and monitor implementation of the roadmap and decentralize it to regional committees.
Health Policy Plus (HP+) marked World Contraception Day this year with a focus on the positive, a welcome distraction from the COVID-19 pandemic, by asking our colleagues and partners, “what about contraception puts a smile on your face?” With a reflection by family planning and reproductive health lead, Jay Gribble, and a photo collage featuring messages from around the world, HP+ demonstrates many reasons to smile as voluntary contraception and method choice continue to improves the lives of women and men, their families, and communities.
On August 25, HP+ supported Madagascar’s Family Health Directorate (DSFA) within the Ministry of Public Health to conduct a virtual semi-annual review and performance monitoring meeting of the country’s costed implementation plan (CIP) for family planning. Using data generated by an online CIP dashboard developed by HP+, meeting participants were able to monitor progress of CIP activities and indicators, identify bottlenecks and solutions, and provide recommendations for the next iteration of the plan. Since adoption of the CIP in 2016, the country’s contraceptive prevalence rate has improved from 33 to 44 percent and maternal deaths averted by family planning have increased from 500 to 2,600.
In Madagascar, HP+ has been supporting journalist trainees to provide information and news about family planning/reproductive health (FP/RH). Twenty news articles have since been produced that reach local, regional, and national audiences. Last November, 11 journalists were trained by HP+ on the fundamentals of FP/RH, the FP/RH law, and issues related to population and development. The following January, with HP+ support, nine of the trainees conducted field investigations to raise public awareness of early pregnancy, break taboos on contraception, and disseminate the FP/RH law. In July 2020, HP+ supported the development of a yearlong editorial calendar and dissemination strategy to support these efforts.
In May, HP+ supported Madagascar’s Ministry of Public Health’s Family Health Directorate to convene two virtual meetings with the multisectoral family planning committee to address decreases in family planning and maternal and child health service use nationwide. The meetings resulted in development and finalization of a budgeted action plan to ensure continuity of family planning service availability for the 27 districts under stay-at-home orders imposed as a result of COVID-19. Plan activities include ensuring continued availability of family planning products, extending the DMPA subcutaneous auto-injection approach in three regions to prolong the amount of time between visits to health facilities, and emphasizing community health service provision.
In May, with HP+ support, Madagascar validated its new Water, Sanitation, and Hygiene (WASH) sector policy through a virtual workshop led by the WASH minister and attended online by nearly 80 key stakeholders. Adoption of the new policy is a significant achievement within the context of the COVID-19 pandemic, as it enables health facilities to install running water to support handwashing guidelines. Policy implementation, which will be facilitated through the forthcoming national WASH Strategy, aims to enable public access to potable water for the entire population by 2030—a significant increase from the current level of less than half of the population with access.
An HP+ webinar delivered by Christine Lasway and Laura Hurley on May 14 – What’s Measured Matters: Monitoring Family Planning Costed Implementation Plans – presented an overview of the CIP Performance Dashboard, a data management tool to track CIP performance targets. The discussion included case studies from Madagascar and Ghana, countries using it to monitor execution of their CIPs. The CIP Performance Dashboard, available in Excel and now as an online tool, was developed based on DHIS2. This webinar is ideal for stakeholders looking for a strategic planning performance monitoring tool.
In Madagascar, the Ministry of Public Health’s Family Health Directorate (DFSa) is using a web-based dashboard tool to facilitate data analysis and visualization as part of its semi-annual costed implementation plan (CIP) execution review meetings. HP+ developed the dashboard and trained the DSFa and CIP committee on its use. The dashboard, which is owned by CIP committee members, allows for strategy adaptation and orientation for improved family planning programming and CIP implementation in the country. The dashboard encourages country ownership of the CIP process and progress toward achieving its goals, including increasing the contraceptive prevalence rate to 50 percent.
In December 2019, Madagascar integrated a tax exemption for contraceptives into the country’s finance law. The exemption, which will remove the 20% value-added tax applied at customs, followed HP+ support to the Ministry of Public Health’s Family Health Directorate to write advocacy messages encouraging key decisionmakers to make contraceptives tax-exempt. This exemption will reduce purchase costs, contributing to operationalization of the new Reproductive Health and Family Planning Law (2018) that promises access to contraceptives for all, and encourage private sector engagement in family planning service delivery.
A key component of successful advocacy is engaging media to promote issues relevant to a wide audience in order to build awareness of critical issues and garner support for change. To this end, HP+ conducted a training workshop for national journalists on the fundamentals of family planning and reproductive health (FP/RH) and their importance in underpinning the country’s development and future growth. The workshop, held November 12-14 in Antananarivo, brought together 11 national and local journalists from radio, television, and print media to learn about the importance of FP/RH and provided the opportunity to role play interviews with health workers and clients from primary healthcare centers. Moving forward, HP+ will serve as a bridge between journalists and experts on FP/RH in Madagascar, supporting journalists to network with and source their information from knowledgeable health personnel. As a follow up with a stipend from HP+, each journalist will undertake investigative reporting on topics such as early pregnancy, early marriage, barriers to family planning use, access to family planning services, and family planning for homeless people to be published in January and February. These stories on reproductive health will bolster advocacy efforts.
In Madagascar, HP+ has been working to support efforts to harness the demographic dividend as the country’s age structure shifts toward a larger workforce, boosting economic growth. On September 12, the Ministry of Economy and Finance, with support from HP+ and UNFPA, organized the official launch of the country’s Demographic Dividend Roadmap at an event in Antananarivo. The event, which brought together stakeholders involved in coordination of activities aimed at achieving the demographic dividend, was attended by the Minister of Economy and Finance Richard Randriamandrato and actors from the public and private sectors, civil society, and technical and financial partners. At the launch, Randriamandrato formally validated the roadmap and discussed the importance of considering the country’s family planning/reproductive health law in efforts geared toward achieving the demographic dividend. At the end of September, HP+ is supporting the Ministry of Economy and Finance to finalize a follow-up plan, including details on monitoring and evaluation, budgeting, and resource mobilization for key activities.
HP+ worked with Madagascar’s Directorate of Family Health and the Ministry of Public Health’s Health Promotion Team to create a poster and job aid for health workers to disseminate information about a 2018 law on reproductive health and family planning and its associated decree. Since the law’s passage, the ministry and HP+ have been working to ensure that all Malagasy citizens know of and understand their rights to voluntary, rights-based reproductive health and family planning services, and that health providers understand their responsibility to provide these services to all. The job aid and poster outline the key points of the law in a simple, comprehensible format in the Malagasy language to aid understanding of and ownership over the rights and responsibilities defined by the law.
Madagascar’s National Universal Health Coverage (UHC) strategy includes a vision to develop a comprehensive health financing mechanism that will extend the reach of a high-quality essential package of services to more people, especially the poor. As part of this effort, the government is now piloting the National Health Solidarity Fund, a candidate mechanism, to advance the health system towards universal health coverage. To inform health reform decision-making, the USAID-funded Health Policy Plus project conducted an assessment of Madagascar’s current health financing arrangements. Findings from the assessment suggest that Madagascar has a low revenue base, and the health sector relies heavily on donors and out-of-pocket payments to fund key programs and health facility costs. Like many other low-income countries, use of health services is low, health financing pools are fragmented, and financing mechanisms cannot guarantee an essential package of services for most citizens. The assessment also identified opportunities to increase efficiency in budgetary allocation and execution. As the country pilots the National Health Solidarity Fund, this landmark assessment comes at a critical time to inform policies aimed at maximizing financial protection for the poor and vulnerable.
On December 12, 2017, the Senate of Madagascar passed a landmark reproductive health and family planning law that marked the final step in the law's adoption, following approval by the Council of Government, the Council of Ministers, and the National Assembly earlier in the year. The president's promulgation of the new law will be a tremendous step forward toward rights-based reproductive health services in Madagascar, which had been operating under a 1920s French colonial framework that prohibited distribution of contraception to youth or married women without spousal consent. HP+ was integral to this win, providing technical and financial support to revise the law and advocate to decisionmakers at each step of the approval process. HP+ Madagascar continues to support the new family planning law by supporting CIP execution; mobilizing family planning resources; supporting the development of application decrees for the law; working with a team to develop communication materials to disseminate the law; and monitoring the progress of actions that contribute to an enabling legal environment. In FY19, HP+ Madagascar plans to finalize an animated film to help disseminate the law and work with civil society organizations to both promote the law and hold the government accountable for dissemination and adherence to the law.
Madagascar's government council passed a decree in April 2017 establishing a national health solidarity fund as part of its universal health coverage (UHC) efforts. The solidarity fund, called Caisse Nationale de Solidarité en Santé(CNSS), aims to cover the cost of preventive, curative, and rehabilitation care for its affiliates, which will be provided nationally via a third-party payment system. The USAID-funded Health Policy Plus (HP+) project provided technical and financial support to the Ministry of Health's universal health coverage division to develop the decree with a broad group of public and private stakeholders. This is an important step for Madagascar following the launch of the UHC strategy, but there is still a long road ahead. HP+ Madagascar will continue to work with the government on next steps, including establishing a clear benefits package and determining the payment structure.
Madagascar’s current family planning (FP) law was adopted around 1920, and restricts contraceptive access to young people. HP+ co-facilitated a workshop on Advanced Family Planning SMART to train stakeholders on FP advocacy techniques and develop a plan of action to assure that the country’s newly revised family planning and reproductive health law—created with drafting and technical review support from HP+—is reviewed and passed by parliament this year. The project is also active in the development and advancement of universal health coverage (UHC) and is represented on the UHC technical working group. The project has collaborated with the World Bank to introduce the RMNCAH (reproductive, maternal, newborn, child, and adolescent health) investment case to the MOH, and will support the ministry in its development.
Appearing at Madagascar’s First National Family Planning Conference (September 13–16), the head of the Ministry of Health (MOH) family planning division presented on findings from an application of ImpactNow, a USAID-supported model available through HP+. The division head highlighted that Madagascar could prevent over 4 million unintended pregnancies and 12,000 maternal deaths by 2020 if modern contraceptive prevalence increases to 50 percent among married women. The presentation material is also available as a brief.
At the conference conclusion, the MOH director of family health presented and highlighted the importance of key elements of the Costed Implementation Plan (CIP) for family planning. The CIP development process has been guided by HP+ and is close to completion in Madagascar. The country will join other FP2020 countries with a comprehensive roadmap to achieve its FP2020 goals by late 2016.