World health report

Primary Health Care in Action

Country examples


Madagascar in numbers1

  • Life expectancy (both sexes, 2006): 59 years
  • Gross National Product per capita (PPP in international $, 2006): 870
  • Per capita total expenditure on health (PPP in international $, 2005): 33
  • Number of physicians (per 10 000 population, 2005): 3


  • Life expectancy has increased since 1990, polio has been eradicated and infant mortality is declining
  • Islanders have never been more motivated to look after their health
  • Only 60–70% of the population has ready access to primary health care services
  • Health centres in a poor state of disrepair

When the first batch of 1500 young health aides was dispatched in 1980 to Madagascar’s villages, it was thought to herald a new era in health care for the island nation off the south-east coast of Africa.

The project was the centrepiece of the country’s primary health care programme, launched in 1978 with high hopes of meeting the Alma-Ata goal of providing health for all by 2000.

The ‘health for all’ idea was not to eradicate every disease, but to attain an acceptable level of health, equitably distributed throughout the world. The results in Madagascar, however, have been mixed, with strong advances in some areas and little progress in others.

On the plus side, islanders today have never been more motivated to look after their health, says Professor Dieudonné Randrianarimanana, cabinet director of the Madagascar Ministry of Health, Family Planning and Social Protection.


Currently, average life expectancy is 59 years which represents an increase of about 6 years from its 1990 level. Poliomyelitis has been eradicated. Officials there say the prevalence of leprosy is less than 1 per 10 000; and infant mortality is decreasing (in 2006 the probability of dying in the first year of life was down to 72 deaths per 1000 live births compared with 84 in 2000 and 103 in 1990).

But 30 years on, only 60–70% of the population has ready access to primary health care, officials say. Many people still have to walk 10 kilometres or more to receive treatment, though mobile health centres have been introduced in remote and sparsely populated areas.

Like Randrianarimanana, nurse Florentine Odette Razanandrianina has experienced the ups and downs of primary health care. She arrived in the village of Ambohimiarintsoa, 200 kilometres from the capital Antananarivo, in October 2006 to run the health clinic.

She provides twice-weekly prenatal and postnatal check-ups. She also offers child immunization and vaccination, family planning services and disease treatment.

But five of the centre’s seven small rooms are in a poor state of repair and lack sufficient equipment, Razanandrianina says. “We have five mattresses for only one bed. Consequently, we are often obliged to let patients sleep on the mattresses placed directly on the soil.”


There are many other health centres in a similarly poor state of disrepair across Madagascar, officials admit.

Also, frictions can arise when modern practices are perceived as counter to traditional customs. Since moving to the village, Razanandrianina’s efforts to teach people about the need for personal hygiene have not always been welcome.

Despite these setbacks, Razanandrianina has not curtailed her efforts. For example, when people from villages further away have chosen not to attend vaccination clinics, she has gone to them.

“Every time we visit the remotest villages, people wait for us in a group. They really appreciate our visits,” Razanandrianina says.

This is an abridged version of an article published in the Bulletin of the World Health Organization in June 2008.

1World Health Statistics 2008, Online version: (accessed on 26/09/2008)

2Primary health care: back to basics in Madagascar, WHO Bulletin, Vol 86 (6),