Health System Strengthening in Madagascar

Closing the global health delivery gap is often framed as in issue of scale-up. There is little evidence on the process by which healthcare systems improve at the point of service and how that, in turn, impacts population health.   There is no gold standard, equivalent to randomized trials, for health systems research. We have created a new framework for district-level health system strengthening in Madagascar.  The program simultaneously strengthens the WHO’s six building blocks of HSS at all levels of the health system within a government district, while pioneering a data platform that includes 1) strengthening the district’s health management information systems (HMIS); 2) nongovernmental monitoring and evaluation dashboards; and 3) a prospective longitudinal cohort demographic and health study of over 1500 households. The data platform allows for the evaluation of system output indicators as well as population-level impact indicators, such as mortality rates.


A New Platform for Health System Strengthening. The platform, which is formed in partnership between the Ministry of Health, nongovernmental and academic partners, provides a feedback system between 1) health system interventions at the community, health center, and hospital levels across a government district, and 2) information systems of routine data and a population-based longitudinal cohort study. The right panel is a map of the interventions in Ifanadiana District.



Malnutrition Program. The process of strengthening health systems occurs through a series of individuals initiatives, such as 1) this malnutrition program, which we implement at the community, health center, and hospital levels in the government district. 2) Data are routinely collected to analyze the effectiveness of the malnutrition program. 2) The longitudinal cohort study indicates spatial distribution of malnutrition in the district. These data are monitored over time for measuring population-based impacts.


As a result of our programs, patient utilization rates have risen dramatically (Garchitorena et al; 2017)

Selected Publications

  1. Bonds MH et al, 2017, “Advancing A Science For Sustaining Health: Establishing A Model Health District in Madagascar,” BioRxiv, 141549.
  2. Miller AC et al 2017, “Baseline population health conditions ahead of a health system strengthening program in rural Madagascar,” Global Health Action, 10: 1329961.
  3. Garchitorena et al, 2017, “In Madagascar, use of health care services increased when fees were removed: Lessons for Universal Health CoverageHealth Affairs, 36:1443-1451.