Madagascar

Under article 19 of the Constitution, the State recognizes and organizes for all people, the right to health protection from birth, through the organization of free public health care, which is free of charge as a result of national solidarity.

There is no specific reference in the Constitution to competencies over health matters. Matters to be addressed by the law are specified under article 95 of the Constitution and include, among others, the creation of categories of public establishments, the organisation and operation of decentralised local authorities, nature and basis of taxation of decentralised local authorities, and land use planning and housing; the law further set fundamental principles in the area of labour law and social security (non-exhaustive list).

The main goal of the 2016 National Health Policy ("Politique Nationale de Santé, Août 2016") is to ensure the well-being of the Malagasy population by providing quality and accessible health services for all, based on the principles of equity, quality, comprehensiveness, and universality to ensure a better and productive life (page 16).

The policy identifies several objectives, including improving the supply and utilization of health services, reducing maternal and neonatal mortality, and reducing mortality among children under five years old (pages 16-17). Strategies to achieve these objectives include strengthening the health system, improving access to health services, ensuring the availability and rational management of health inputs, and developing partnerships (pages 17-21).

The situational analysis (section 2, page 9) outlines the updated Health Code and the Law on Hospital reform as key legal texts for health. A broader inventory of applicable legal texts is provided in the foundations section of the policy (section 3, page 13) which includes, in addition to the Public Code (Loi 2011-002) and the Law on Hospital reform (Loi 2001-003), the Law 97-004 on people with disabilities, the Law 2004-029 banning smoking in public and working places, the Labor Code (law 2003-044) and the Water Code (Law 98-029).

As part of priority action areas, the Policy references the update of legal framework especially family planning laws and regulatory texts relating to the marketing of breast-milk substitutes (page 18), the implementation of the hospital reform and compliance with the hospital regulatory norms (page 19).

The main goal of the National Health Sector Development Plan 2020-2024 ("Plan de Développement du Secteur Santé 2020-2024") is to reduce morbidity and mortality caused by diseases and adverse health events by contributing to better health (page 73). The three specific objectives pursued are to: strengthen preventive, promotional interventions for diseases and preparedness for effective response to health emergencies and disaster (pages 74-76); improve the availability and use of quality health services equitably at health structures (pages 76-80); ensure the availability and efficient management of resources for an effective and resilient health system (pages 80-82) and strengthen the efficient management system of health programs based on evidence for mutual accountability at all levels of the health system (pages 82 -85).

The situation analysis section outlines several issues re the current legal and regulatory framework (section 1.1.1.1, page 19). Each program has legal and regulatory texts, but their implementation faces issues such as delays in government adoption, procedural complexities, and insufficient communication. The foundational texts for the National Health Solidarity Fund ("Caisse Nationale de Solidarité pour la Santé" (CNSS)) are still awaiting approval while former texts have already been repealed (Decree 2017-0601 and decree 2018-0473). The development of Universal Health Coverage in Vatomandry is hindered by the facts that the orders setting reimbursement modalities by the CNSS, contributory modalities for the participants, and benefits package are not yet finalized. The vaccination law's application decree and standards are not yet available. Regulatory texts for the center of emergency medical aid ("Centre d'Aide Médicale d'Urgence de Madagascar" CAMUM) are still being developed, and the legal framework for INSPC is outdated. There is resistance to applying reference texts in hospitals (e.g. for pricings, training requirements). Important aspects of the WHO Framework Convention on Tobacco Control are not covered by current legislation. The regulatory environment for medications lacks application texts for clinical trials and post-marketing surveillance. The FANOME system does not include financial participation for district and hospital pharmacies, necessitating an amendment to decree No. 2003-1040. Among main challenges encountered, implementation gaps and lack of clarify of legal and regulatory frameworks are mentioned (page 72).

The plan references several legal and regulatory actions under the three specific objectives. This includes establishing a legal framework for family planning to enable the implementation of the law on sexual and reproductive health and family planning (page 73), better communication of existing legislation and regulations for hygiene and safety norms (page 74), enhanced implementation by relevant stakeholders of the legal texts on community health (pages 79, 94,95,110), Setting up/updating the legal framework (laws, decrees and implementing orders, etc.) governing FANOME and the Equity Fund (pages 82, 113), strengthening the implementation of legal and institutional frameworks for health (pages 82, 99, 113).

p 82 - Mise en place/Réactualisation du cadre juridique (lois, décrets et arrêtés d'application...)
régissant le FANOME et le Fonds d’équité