Madagascar - GFDRR

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Damage, Loss, and Needs Assessment for Recovery and Reconstruction: Madagascar 47 According to the 2003 National Health Accounts, total health expenditure, which accounts for 3.5 percent of GDP, was estimated at approximately 11.9 USD per capita (the average in Africa is on the order of 12.9 USD). This average is well below the 34 USD per capita rate recommended by the WHO’s Commission on Macroeconomics and Health to finance basic health needs, and HIV/AIDS. Overall, 32 percent of the expenditures on the health sector are financed by the public sector, 36 percent by donors, and 32 percent by the private sector. Prevention and public health services account for 28 percent of total health services expenditures. 13 Thus, the current health system does not offer financial protection that has been tailored for the majority of the population who are in dire need of health care. Indeed, 68.7 percent of the population lives below the poverty line, and 23 percent of those who seek health care encounter financial difficulties. 14 Prohibitive health care costs prevent them from making appropriate use of hospital services. While mutual health associations exist, they are still too few in number and fail to reach very poor families. National and international NGOs operate in several public health areas in Madagascar. However, only a handful of NGOs manage to conduct nationwide operations, because the NGO interventions are, for the most part, concentrated in relatively accessible areas. Furthermore, added to the dearth of resources and expertise is the lack of NGO coordination at the national level, which contributes to duplication of activities. The private sector covers only approximately 15 percent of all health facilities in the country. This low level of coverage is offset to some extent by better equipment, which serves as a resource for the ill from affluent socioeconomic backgrounds. In this generally hostile context, basic health indicators remain worrying, despite significant strides, particularly in the area of child health. These indicators include a high maternal mortality rate of 469 per 100,000 live births, a neonatal mortality rate of 32 per 1,000, while only 47 percent of births are attended by skilled staff, and 32 percent of births take place in health facilities. Natural or man-made disasters (annual cyclones or floods, drought in the south, and the sociopolitical crisis of 2002) only exacerbate the incidence and prevalence of these communicable diseases, and of other recurring health problems such as child malnutrition. Thus, in recent times, cyclones have determined the rate at which malaria (in Figure 14: Hospital destroyed by the cyclones the highlands or in the south), cholera (at the beginning of the 2000s), and arbovirus (dengue and chikungunya in 2006, Rift Valley fever in 2008) epidemics have developed, while the sociopolitical crisis of 2002 was undoubtedly one of the factors that strengthened the 2002 flu epidemic. The effects of the cyclones during 2006-2007 are still being felt in 13 National Health Accounts, 2003 14 Household Survey, January 2006
48 Damage, Loss, and Needs Assessment for Recovery and Reconstruction: Madagascar 2008, as severe malnutrition plagues the southeast regions. Rural areas, particularly the coasts, which are very exposed and vulnerable to these hydrometeorological hazards, are most adversely affected by the dearth and inequitable distribution of health staff. Indeed, the current ratio in Madagascar is 1.05 health workers per 1,000 inhabitants, which falls short of the standard of 2.5, considered to be the threshold for having a significant impact on the population’s health. Moreover, almost 50 percent of the ministry’s staff is concentrated solely in the Analamanga region (capital region) and in a number of hospitals in the major cities. Similarly, the distribution of doctors among rural and urban areas reveals an acknowledged imbalance, to the detriment of the rural populations. For example, the former Antananarivo province, which is home to 28 percent of the country’s population, employs 46 percent of all doctors working in the public sector. 15 The capacity of the health service to prepare for, and respond to, these disasters is often overwhelmed. Specifically, the disease surveillance system is still barely operational, and the capacity of health officials at the peripheral levels to counter epidemics and provide adequate treatment for serious cases remains limited. Damage and Loss Assessment The 2008 Cyclone Season, particularly cyclones Fame and Ivan, did not spare the health sector. In addition to the approximately 100 deaths, some 600 persons were injured during the cyclone season. Wind or water destroyed or damaged 167 basic health centers (CSBs), or approximately six percent of the total, as well as six hospitals, hitting the Analanjirofo and Haute Matsiatra regions the hardest. Overall damages were estimated at Ar. 11,230.0 million (US$6.8 million) and losses at Ar. 5,690.5 (US$3.4 million). Table 15: Damages and Losses in the Health Sector (Million Ar.) Disaster Effects Ownership Macro-Economic Impact Damage Losses Total Public Private BOP Fiscal Sector Infrastructure 10,976.1 10,976.1 10,976.1 2,195.2 Equipment and furniture 242.8 242.8 242.8 194.2 Medicines and supplies 11.1 11.1 11.1 10.0 Losses of revenues 3,239.8 3,239.8 3,239.8 3,239.8 Medical attention to 765.9 765.9 765.9 765.9 injured Higher cost of medical 467.4 467.4 467.4 467.4 care Prevention campaigns 622.8 622.8 622.8 622.8 Cost of demolition 594.6 594.6 594.6 594.6 Total 11,230.0 5,690.5 16,920.5 16,920.5 2,399.4 5,690.5 15 Ministry of Economy, Finance, and Budget; the Directorate General of the National Statistical Institute [Direction Générale de l’Institut National de la Statistique+; the Department of Demography and Social Statistics *Direction de la Démographie et des Statistiques Sociales]: Population and Health Survey, EDSMD-III, Madagascar 2003-2004.
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Madagascar - GFDRR

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