Health Issues in Madagascar: State of the Art Report

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Executive Summary:Madagascar is an island nation located to the south east of the African continent. It is the fourth largest island by area in the world. The country is made up of the main island as well as a number of outlying smaller islands. As of 2014, Madagascar had a population of twenty two and a half million people (World Population Review, 2016). The main economic activities in the country are agriculture, manufacturing, and tourism. The level of poverty in the country is very high. Approximately 69% of the countrys population lives on less than a dollar a day and 90% of the population lives on less than two dollars a day while nominal GDP according to 2014 IMF figures stood at $468 per person (Trading Economics, 2016). The country faces numerous healthcare issues that can be solved using emerging technology such as USSD mobile-based systems, as well as, telemedicine. These solutions have been discussed in the paper below.

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Madagascar faces numerous issues within its healthcare sector. According to The World Bank (2015), in 2010, Madagascar had a total of 3150 doctors, 5661 nurses, 385 community health workers, 175 pharmacists, and 57 dentists serving a population of 22.5 million people (The World Bank, 2015). This results in a ratio of 1 doctor to every 7100 people which is much lower than the WHO recommended ratio of 1 doctor for every 600 people (WHO, 2016). The ratio for total health workers to population is also very low at approximately 1 health professional for every 2,500 people which is well below the recommended ration for doctors only. The country also reports a ratio of three hospital beds for every 10000 people, which is a very low figure (The World Bank, 2015).

The Madagascar government is responsible for about 70% of the healthcare funding in the country and as per 2012 figures, this places per capita government spending on health at 39.7 (Simon, 2012). The rest of the funding comes from private organizations and foreign Non-Governmental Organizations. Consequently, the government provides a health facility for every major community in the country. This helps to reduce the distance between the population and a health facility. This is important to reduce accessibility issues. Despite these efforts, the health facilities especially in rural areas are basic facilities and patients needing specialized treatment have to seek assistance in major healthcare facilities located in urban centers.

Figure 1: Political Map of Madagascar

Existing Solution:Due to the unique problems facing the countrys healthcare system, the most appropriate existing solution towards addressing the problem is prevention of disease in the country. Because of the high levels of poverty in the country and lack of enough healthcare professionals, treatment of diseases becomes a major problem. This means that preventive measures are the most efficient and cost effective measures to handle healthcare problems in the country. A case study of preventive healthcare is Cuba. Cuba has faced economic sanctions for over 50 years, which have affected the economy greatly. This means that Cuba spends much less on healthcare than most developed and developing countries (Whiteford & Branch, 2008). Despite this, Cuba has a very efficient healthcare system, which regularly outperforms many richer countries. For example, Cuba spends less than a fifth per head of what the United States spends on healthcare but with better results (Brouwer, 2011). For example, Cuba has a lower infant mortality rate than the United States and a similar life expectancy. This is because of its preventive approach to healthcare rather than curative.

Preventive measures typically cost less than curative measures, which is attractive to poor countries (Brouwer, 2011). This approach has helped to improve healthcare services in Madagascar over the last three decades (Janes & Lundy, 2016). For example, childhood immunization against diseases such as measles and hepatitis B increased by over 60% during this period. The cost of administering vaccines is much lower than the cost of treating the actual diseases (Janes & Lundy, 2016). However, there are differences between the best-case scenarios in this case Cuba, and Madagascar. Cuba has a much higher healthcare professional to population ratio than Madagascar. This in itself is a challenge to healthcare in Madagascar. Infant mortality is also very high in Madagascar, mainly because of high fertility rates in the country. The fertility rate in Madagascar stood at 4.5 children per woman according to 2013 WHO figures, which is significantly higher than many countries and therefore is reflected in infant mortality rates (WHO, 2016) Teenage pregnancies also contribute to high infant mortality rates with a national figure of just under 15%. This is a problem since teenagers are not fully developed leading to complications during pregnancy.

Emerging Technology:There are a number of emerging technologies that can be used to assist solve the problem. The most common of these technologies is mobile technology. Africa has growing mobile phone coverage and this can be used to the advantage of the country. Mobile penetration is growing due to the relatively cheaper cost of infrastructure compared with fixed telephone lines. Mobile handsets are also becoming cheaper which means that more people can afford mobile handsets to keep them connected. Madagascar is an example of a country where the cheaper cost of laying down mobile infrastructure has led to a growth in the uptake of mobile phones (Maeder, 2014). As a result, they can be used to help in managing the health issues in the country. Many countries in sub-Saharan Africa have tried out mobile based health applications. These can either be based on online platforms or USSD platforms (Maeder, 2014).

USSD platforms are preferred in this case because of the relative cost. USSD solutions make use of short message services and can therefore be used with low cost phones (Maeder, 2014). For example, a mobile application for pre-natal and postnatal maternity care has been successfully tried and used in Kenya, a country in the east African region. The application provides information for mothers in an easy and cost effective way. For example, a mother can know when their check-ups are due and the app can also provide basic information to queries from the mothers. Similar applications can be used to reduce the cases of infant mortality in Madagascar. The relative cost for such an application is very low, usually translating to less than a dollar a month for the end-user. Such costs can further be reduced by subsidies from the government. Similar applications can be developed to provide information for a variety of health issues such as information on prevention of malaria and other non-communicable diseases (Maeder, 2014).

The technology described above would be beneficial to the people of Madagascar since it would lead to increased access to healthcare. Access to healthcare remains a major problem in Madagascar. The high level of poverty in the country with over 90% of the population of 22.5 million living below the global poverty line of $2 a day, access is a major issue (Trading Economics, 2016). This means that the people are not able to afford the cost of healthcare. Furthermore, the lack of infrastructural development implies that almost 40% of the population does not have access to primary healthcare (WHO, 2008). The use of USSD technology can help increase access to healthcare for the population.

Figure 2: USSD based patient management system

Figure 3: System Diagram for USSD based system

Another emerging technology that can be used is telemedicine. This would play an important role in increasing access to healthcare as a result of the limited number of healthcare professionals. The available healthcare professionals would provide their services on an online platform meaning that they would be able to reach more people who require their services. This is a technology that has been used with success in many areas of the world (Davis & LaCour, 2014). For this service to work in Madagascar, the government would ensure that its health facilities have an internet connection, which would be used to enable doctors and other healthcare professionals in urban areas to provide their services to people who visit the rural facilities which would otherwise not have a qualified health professional. In addition to healthcare professionals from within the country, patients would also have access to medical professionals from various regions in the world. This would be possible at a significantly lower cost than the cost of the patient travelling to seek similar services.

Telemedicine is important since it will overcome the issues posed by Madagascars geography. The geography of the country also plays a major role in limiting access to healthcare for many people. The central highlands and the eastern coast are the most populated regions in the country because of the countys geography. Majority of the urban centers in the country are located in these regions. According to statistics from WHO (2016), in 2013, 34% of the population in Madagascar lived in Urban areas. Despite being densely populated, these regions make up less than a third of the total area of the country. This means that there are large areas, which are sparsely populated. With majority of health facilities located in urban areas, this means that people living in the rural sparsely populated regions find it difficult to access medical facilities. The limited number of health workers in the country further complicates this fact.

Figure 4: System diagram for telemedicine

Conclusion:In conclusion, the benefits of such technologies are that they have been tried in other countries and have been seen to have positive results. This means that the country would be using technology that is proven to work. The cost of implementing such technologies has also dropped meaning that it would be cost effective to implement them. The major disadvantage would be the rate of adoption in some regions in the country. The government would have to conduct sensitization campaigns in these regions in order to ensure that people know about the applications before they can even use them. This would increase the overall cost of implementing the technology.


Brouwer, S. (2011). Revolutionary doctors: How Venezuela and Cuba are changing the world's conception of health care. New York: Monthly Review Press.

Davis, N. A., & LaCour, M. (2014). Health Information Technology. London: Elsevier Health Sciences.

Janes, S., & Lundy, K. S. (2016). Community health nursing: Caring for the public's health.

Maeder, A. J. (2014). Global telehealth 2014. Amsterdam: IOS Press.

Nepomichene, T. N., Tata, E., & Boyer, S. (2015). Malaria case in Madagascar, probable implication of a new vector, Anopheles coustani. Malaria journal, 14(1), 1.

Simon, R. (2012) Healthcare spending around the world, country by country. Retrieved 2/9/2016 from World Bank (2015) Implementation Completion and Results Report. Retrieved 2/9/2016 from

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