Action Against Hunger is helping to transform health planning in Madagascar

A major reform to bring decision-making closer to people’s needs

In Madagascar, a major reform is changing the way in which health priorities are set. Led by the Ministry of Public Health with the support of Action Against Hunger (ACF) and Action Socio-sanitaire Organisation Secours (ASOS), this reform aims to give local stakeholders and communities a greater say in decisions affecting their health. The aim is simple: to draw up district health development plans (PDSDs) that genuinely meet the needs of local areas whilst remaining aligned with national guidelines. This development marks an important step towards health systems that are more effective, more participatory and closer to the people. 

Health planning involves defining a district’s health priorities for the coming years. It enables the identification of key challenges, the selection of actions to be implemented and decisions on how to use available resources. This process is essential: it largely determines the health services that will be provided to the population and the investments that will be made. However, in many contexts, health planning often remains a technical exercise carried out by a limited number of stakeholders, leaving little room for local realities and community participation. 

Over ten years of ACF’s commitment to strengthening local health governance 

For over ten years, Action Against Hunger has been supporting the strengthening of health systems in Madagascar, with the ongoing support of the French Development Agency and in partnership with the Ministry of Public Health and ASOS. In many health districts, notably Morombe, Bétioky, Tulear I, Tulear II, Ambovombe and Antananarivo, teams have worked with local health authorities to improve the governance of the health system and strengthen planning mechanisms. This approach is based on several principles: 

• Meaningfully involving the various stakeholders concerned with health; 
• Drawing on available data ; 
• Building on local realities ; 
• Ensuring consistency with national policies. 

The aim is to enable local decision-makers to better identify priorities in their area and to collectively develop appropriate solutions. 

Connecting national priorities with realities on the ground 

For a long time, health planning in Madagascar has mainly followed a top-down approach: guidelines were set at national level and then rolled out locally. This structure ensured consistency in health policies across the country. However, officials at district, health centre, municipality and community levels had little scope to put forward their own priorities. The current reform seeks to better coordinate these two levels. On the one hand, it maintains the national strategic guidelines set out in the national Health Sector Development Plan (PDSS). On the other, it gives greater weight to locally identified needs. The aim is not to pit national and local priorities against one another, but to bring them into alignment in order to enhance the effectiveness of the health system. 

A new public policy for the country 

This reform represents a major development for the Madagascan health system. It introduces a new health planning model based on a bottom-up, participatory and multi-annual approach, enabling better alignment between needs expressed at local level and national strategic guidelines. 

Its ambition is considerable: to enable Madagascar’s 119 health districts and 24 regions to draw up five-year local Health Development Plans, aligned with the Health Sector Development Plan (PDSS) whilst addressing the specific circumstances of each territory. 

Beyond being a mere planning exercise, these plans serve as a tool for strategic steering and dialogue with technical and financial partners. They aim to improve the health system’s accountability to the population, enhance the coherence of investments in the health sector, and strengthen the allocation of resources in line with the priority needs of the population. 

When experience on the ground informs public policy 

This reform was not developed in a matter of months. It is the culmination of more than a decade of work carried out by Action Against Hunger and its national partner ASOS alongside the Madagascan health authorities. Since 2015, several projects to strengthen health systems have enabled the development, testing and improvement of health planning approaches in various districts across the country. The originality of this approach lies in its phased implementation. The tools and methods were first piloted on a small scale, then evaluated, adjusted and documented before being gradually integrated into the strategic planning of the Ministry of Public Health. The Morombe district marked a decisive stage in this process. The full-scale trial of the future national Health Planning Guide demonstrated the feasibility of the approach and generated practical lessons for its improvement prior to its nationwide roll-out. 

The official validation of the National Guide and the launch of the reform now mark the transition from a grassroots innovation to a public policy driven by national institutions. 

Prior to its nationwide roll-out, the new approach was piloted in the Morombe district, in the Atsimo-Andrefana region. The evaluation revealed several encouraging results. The process helped to strengthen the district’s role in health planning and to ensure that the needs expressed by health centres and communities were better taken into account. It also fostered the development of more collaborative and transparent governance. Finally, the following was observed: 

• better use of data to inform decision-making; 
• strengthened dialogue between health services, local authorities and partners; 
• the revitalisation of existing consultation forums; 
• a better structuring of the planning process. 

However, the evaluation highlights the financial constraints, which remain considerable. A significant proportion of the activities identified still depend on external funding, which is not always guaranteed. 

A concrete example of ACF’s technical assistance role  

For Action Against Hunger, this reform also represents a particularly innovative endeavour. Traditionally recognised for its operational interventions among vulnerable populations, the organisation has here drawn upon another aspect of its expertise: providing technical assistance to public institutions. 

This technical assistance does not involve taking the place of the health authorities. On the contrary, it is based on long-term support that enables lessons learnt on the ground to be fed back, observed results to be documented, innovative approaches to be tested and national strategic discussions to be informed. 

The Madagascan experience thus demonstrates that an NGO can act as a bridge between the realities on the ground in health districts and public reform processes. By combining operational expertise, a partnership with a national organisation such as ASOS, and constant dialogue with health authorities, ACF has helped to transform a series of local experiences into a methodological framework that has now been adopted at national level. 

A further step towards universal health coverage in Madagascar 

By improving the quality of health planning, this reform contributes directly to the national objectives of strengthening the health system and to progress towards the Universal Health Coverage. It aims to improve coordination between stakeholders, make more efficient use of available resources, and ensure that decisions are more closely aligned with the realities experienced by the population. Beyond the planning tools themselves, the reform affirms a fundamental principle: the health district is the level at which public policies are translated into concrete health services for citizens. Strengthening the leadership of district teams is therefore a strategic investment in sustainably improving access to quality health services for all. 

For further details, our scientific publication: “Community case study: Overcoming barriers to social participation for improved health governance Madagascar”