Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Ioana Kruse Kruse Ioana Maryanne Sharp 2000–09 Madagascar in Health, Nutrition, Population and WORLD BANK WORKING PAPER NO. 216 NO. PAPER WORKING BANK WORLD AFRICA HUMANDEVELOPMENTSERIES THE WORLD BANK WORLD BANK WORKING PAPER NO. 216 Health, Nutrition, and Population in Madagascar 2000–09 Maryanne Sharp Ioana Kruse Copyright © 2011 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org 1 2 3 4 14 13 12 11 World Bank Working Papers are published to communicate the results of the Bank’s work to the devel- opment community with the least possible delay. The manuscript of this paper therefore has not been prepared in accordance with the procedures appropriate to formally-edited texts. 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Contents Acknowledgments ....................................................................................................................ix Acronyms and Abbreviations ..................................................................................................x Executive Summary ............................................................................................................... xiii 1. Introduction and Context .....................................................................................................1 Country and Sector Context...............................................................................................1 Objectives and Organization of the Country Status Report ..........................................2 Available Data and Reports ..............................................................................................3 2. Sector Outcomes and Demographic Trends .....................................................................5 Demographic Trends ..........................................................................................................5 Child Health .........................................................................................................................7 Maternal Health ................................................................................................................. 12 Nutritional Status of Children and Women .................................................................. 14 Other Communicable Diseases Contributing to Mortality and Morbidity in Madagascar ................................................................................................................. 16 Non-Communicable Diseases .......................................................................................... 19 Meeting the Millennium Development Goals (MDGs) ............................................... 20 3. Behaviors Conducive to Be er Health Outcomes ........................................................ 25 Behaviors and Interventions Aff ecting Child Health ................................................... 25 Community Factors and Behaviors Aff ecting Nutritional Status of Children ......... 29 Maternal Health and Reproductive Health ................................................................... 36 Communicable Diseases ................................................................................................... 43 Health Care Access and Utilization by the Poor ........................................................... 48 4. Health System Performance .............................................................................................. 56 Sector Organization ........................................................................................................... 56 Quality of Services ............................................................................................................. 66 5. Sector Financing .................................................................................................................. 78 Financing of the Health Sector ........................................................................................ 78 Equity of Health Spending ............................................................................................... 90 Effi ciency Issues of Health Spending .......................................................................... 100 Scope for Creating Fiscal Space ..................................................................................... 104 Potential Impact of the Crisis on the Health Sector ................................................... 105 6. Strengthening Accountability in the Health Sector .................................................... 110 The Importance of Accountability for Health ............................................................. 110 Governance and Accountability in the Malagasy Context ........................................ 111 iii iv Contents Appendixes .............................................................................................................................. 131 Appendix 1. Indicators and Outcomes ......................................................................... 133 Appendix 2. Child Nutrition and Early Childhood Development .......................... 135 Appendix 3. Health Financing ....................................................................................... 138 Appendix 4. Best Practices in RBF from around the World ...................................... 142 Appendix 5. Summary of CSC Ratings in Anosy during implementation and follow-up ................................................................................................................... 143 References ................................................................................................................................ 145 Boxes Box 2.1. Maternal mortality in Madagascar ..........................................................................13 Box 3.1. Maternal knowledge and self-effi cacy.....................................................................32 Box 3.2. Creation of a National Community Nutrition Program .......................................34 Box 3.3. Pilot to cover the direct and indirect costs related to emergency obstetrical and neonatal care in the regions of Boeny and DIANA ...........................42 Box 3.4. Distance to the nearest health center: the case of a village in Majunga region ..................................................................................................................50 Box 3.5. Santé Sud program .....................................................................................................51 Box 4.1. Quality of infrastructure aff ecting maternal and neonatal health ......................68 Box 4.2. Response of the public to suspension of user fees (2001-2004) ............................71 Box 5.1. A brief presentation of Madagascar’s budget execution process ........................85 Box 5.2. Some key elements of the equity funds at the health center level ......................94 Box 5.3. Some key elements of the equity funds at the district hospital level ..................96 Box 5.4. Community Insurance Scheme (Mutuelle) of Ankazomanga-Ouest..................98 Box 5.5. Two examples of pilot community-based health insurance schemes in the regions of Haute Matsiatra and Atsinanana ..................................................................99 Box 5.6. Selected country experiences with decentralization ...........................................103 Box 6.1. Accountability of FANOME and drugs for the poor ..........................................115 Box 6.2. Increasing utilization of basic maternal and child health interventions through RBF ....................................................................................................................122