Analysis of the Health Financing System in Madagascar

In late 2015, the government of Madagascar developed a National Universal Health Coverage strategy. This strategy lays out a vision for eventually developing a comprehensive health financing mechanism that would reach more of the population, especially the poor, with an essential package of services. Madagascar’s Ministry of Public Health is now piloting a candidate mechanism, the National Health Solidarity Fund, to advance the health system towards universal health coverage. The country is also gearing up to receive financial support from the Global Financing Facility. To inform decision-making towards future health financing reforms, the Health Policy Plus project assessed Madagascar’s current health financing arrangements.

This assessment provides a detailed look at the country’s health financing system and analyzes: the current health context and health system structure, the sources of health financing and the flow of funds through government systems, current and planned financial protection mechanisms that pool tax-based public funds and insurance premium contributions, and various limited community-based financing schemes and facility-level cost-recovery mechanisms. It also reviews available data on service delivery and resource generation and use in the private health sector. Findings suggest that the Government of Madagascar has a low revenue base, and the health sector has a high reliance on donors and out-of-pocket payments to fund key programs and health facility costs. Like many other low-income countries, utilization of health services is low, health financing pools are fragmented, and financing mechanisms cannot guarantee an essential package of services for most citizens. Given the country’s limited resource base, there are opportunities to increase efficiency in budgetary allocation and execution. With the government committing to a vision for universal health coverage, and with the piloting of the National Health Solidarity Fund, this assessment is a critical reference for Malagasy policymakers and development partners and can inform policies for reaching more of the population with an essential package of high-quality health services, financed to maximize financial protection for the poor and vulnerable.

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