2015年-世界发展银行全球_Madagascar_Public_Expenditure_Review_2014___Health_Sector_Background_Paper_85页_2mb

Summary of the Madagascar Public Expenditure Review 2014: Health Sector Background Paper

Core Content

This document provides an in-depth analysis of the health sector in Madagascar, focusing on the structure, performance, and equity of public health expenditures from 2006 to 2013. It highlights the challenges faced by the sector since the political and economic crisis of 2009 and evaluates the effectiveness of public health spending in addressing health needs and inequalities.

Main Objectives and Organization of the Health Sector

• The health sector in Madagascar has experienced a lack of strategic leadership since the crisis, with four Ministers of Health appointed between 2009 and 2014.
• The National Health Strategy (2002-2011) was informally extended without an interim strategy, leading to fragmentation and loss of direction.
• A new Health Sector Strategy (2015-2019) is in development, with a focus on maternal and child health, and the Ministry has committed to a Universal Coverage Strategy by the end of 2015.
• The health system is structured in a pyramid model with four tiers of access: basic health centers (CSB I and II), district referral hospitals (CHRD), regional referral hospitals (CHRR), and university hospitals (CHU).

Trends in Health Outcomes

• Since 2009, key social indicators have declined significantly, and Madagascar is unlikely to meet any of the health MDGs.
• Under-five mortality rates dropped from 163 per 1,000 live births in 1997 to 72 per 1,000 in 2008/09, but have since stagnated or increased.
• Chronic malnutrition is widespread, with 53% of children under five stunted and 5.8% wasted.
• Maternal mortality remains high and has not improved over the past decade, with rates of 469 to 478 per 100,000 live births.
• Non-communicable diseases are on the rise, creating a dual burden on the health system.

State of Health Service Delivery

• Essential health services, particularly maternal and child health services, have low coverage and are worsening since the crisis.
• Only 38% of births occur in health centers, and only 44% are attended by skilled personnel.
• Immunization coverage has declined significantly, from 62% in 2008 to 51.1% in 2012.
• Health service delivery is highly inequitable, with the poorest quintile bearing the largest share of the disease burden.
• Key service delivery indicators, such as skilled birth attendance, show significant disparities across income quintiles.

Public Health Financing and Expenditure

• Total public health financing has been increasing in terms of GDP, but remains low compared to international standards.
• The Ministry of Health (MoH) has been the main public health expenditure provider, but its execution rates have been low, with only 50% of the budget executed in some years.
• The deconcentration of MoH expenditures has been a focus, with more funds allocated to peripheral levels of the health system.
• Public health expenditures are largely directed toward recurrent and non-wage activities, with significant variations in how these are distributed across different types of facilities and levels of care.

Functional Allocation of Expenditures

• The functional allocation of health expenditures shows that primary care receives a smaller share compared to other functions.
• The share of wage expenditures is distributed unevenly, with a higher concentration in urban areas and among higher-level facilities.
• Non-wage expenditures are distributed across various budget programs, with a notable shift in focus toward specific disease interventions.

Distributional Analysis of Public Health Expenditure

• Public health expenditures are not evenly distributed across regions and income levels.
• The poorest regions have significantly lower coverage of health services and interventions.
• Out-of-pocket (OOP) expenditures account for a large portion of health spending, especially in the private sector, where they make up 80% of financing.
• The Health Equity Fund aims to provide free access to medicines for the poorest, but its effectiveness is limited due to poor targeting and cultural issues.

Equity and Accessibility Challenges

• Affordability: High OOP costs, especially for medical consumables and transportation, prevent access for the poor.
• Accessibility: Geographic barriers are a major issue, with many rural areas lacking access to health facilities.
• Human Resources: There is an inequitable distribution of health professionals, with a higher concentration in urban areas. The ratio of nurses/midwives to physicians is low, and there is a significant risk of staff retirement in the near future.
• Quality: Poor compliance with diagnostic and care protocols, weak supervision, and limited availability of essential medicines contribute to the low quality of health service delivery.

Key Findings

• Since the 2009 crisis, progress on health indicators has stagnated or reversed.
• The health system is facing a dual burden of communicable and non-communicable diseases.
• Health service delivery is highly inequitable, with the poorest quintile bearing the majority of the disease burden.
• The effectiveness of public health expenditures is limited by low execution rates, poor targeting, and weak supervision and monitoring systems.

Contextual Weaknesses

• Limited strategic direction and coordination.
• Inadequate human resources and infrastructure.
• High out-of-pocket costs and limited financial protection mechanisms.
• Poor quality of care and weak supervision at lower levels.
• Inequitable distribution of health services and resources across regions and income groups.

Recommendations

• Strengthen strategic leadership and develop an interim health strategy.
• Improve the coordination of financing, especially with external partners.
• Enhance the targeting and effectiveness of the Health Equity Fund.
• Invest in human resource development and retention, especially in rural areas.
• Improve the quality of care through better supervision and training.
• Expand access to health services, particularly in rural and impoverished regions.
• Develop a more equitable distribution of health resources across income and geographic groups.