Madagascar: Score Justification Summary

2026

1.1 Antimicrobial resistance (AMR)

1.1.1 AMR surveillance, detection and reporting

1.1.1a National plan for AMR priority pathogens

Score: 100

There is evidence that Madagascar has a national AMR plan that covers the surveillance, detection, and reporting of priority AMR pathogens. The Madagascar National Action Plan for Antimicrobial Resistance (2019–2023) was developed in 2018 and officially validated in 2019, following the country's signing of the UN's political declaration on AMR in 2016 ¹².

The plan prioritizes the establishment of a national surveillance system under its Strategic Axis 2 (p. 10). It includes the clear objective to "Establish a national system for surveillance of antimicrobial resistance in human, animal and environmental health" in line with a One Health approach (p. 11). ³ The plan’s focus on detection is supported by operational activities, such as a project for the "detection of Carbapenemase-producing Enterobacterales (CPE)" (p. 4). ⁴ It also calls for the implementation of a formal reporting mechanism through activities designed to "set up a system for reporting AMR surveillance data," which is operationalized by the country’s reporting to the WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS) since 2017 (p. 9). ⁵

As of September 2025, the official timeframe for this national action plan has concluded, and there is no publicly available updated version. ⁶

1.1.1b Capacity of national lab/lab system to test for AMR priority pathogens

Score: 50

While Madagascar has a developing laboratory network for AMR surveillance, evidence suggests it is not yet fully comprehensive in testing for all nationally prioritized WHO GLASS pathogens.

A national laboratory system is in place in Madagascar that tests for several, but not explicitly all, of the World Health Organization (WHO) Global Antimicrobial Resistance and Use Surveillance System (GLASS) priority pathogens. The Réseau des Laboratoires à Madagascar (RESAMAD) is the national laboratory network responsible for this surveillance. Specific pathogens are mentioned as being of concern or are already part of existing surveillance systems. These are detailed in Section 2.1, "ATOUTS" (Strengths) of the National Action Plan to Combat Antimicrobial Resistance 2019–2023, on page 5, which lists data for Multidrug-resistant tuberculosis (TB-MR), Enterobacteriaceae, and Staphylococcus aureus. ⁷

Further evidence of testing capacity is provided by the GABRIEL network's project, the "Data center for antimicrobial resistance (AMR) in Madagascar and in Burkina Faso" (April 2024). This project aims to reinforce active surveillance by using data from studies focused on the "detection of Escherichia Coli ESBL and Carbapenemase-producing Enterobacteriaceae". ⁸

A 2018 report titled "Addressing AMR in Madagascar: The experience of establishing a medical bacteriology laboratory at the Befelatanana University Hospital in Antananarivo" provides more specific details on tested pathogens for a pilot project between 2015 and 2018. This report presents preliminary data on resistance rates for several GLASS priority pathogens. Specifically, it documents testing for Escherichia coli, Klebsiella pneumoniae, Methicillin-resistant Staphylococcus aureus (MRSA), and Imipenem-resistant Acinetobacter baumannii (Page 64). ⁹

No further evidence identified on the Ministry of Public Health website. ¹⁰

1.1.1c National environmental surveillance for AMR residues/organisms

Score: 0

There is no evidence that the government of Madagascar conducts routine environmental detection or surveillance activities for AMR or antimicrobial residues in general environments like soil or waterways.

According to a Fondation Mérieux report from July 2025, a workshop, which aimed to build a sustainable surveillance system, was attended by representatives from the Ministry of Water, Sanitation, and Hygiene, and the Ministry of Environment and Sustainable Development, alongside the Ministry of Health and the Ministry of Agriculture and Livestock. A primary recommendation from the workshop was the development of a "national platform for AMR data involving all stakeholders (health, farming, environment), indicating such a platform does not currently exist. ¹¹

Section 2.2, Page 6 of National Action Plan to Combat Antimicrobial Resistance 2019–2023, published in 2022, notes, "Currently, Madagascar does not have a laboratory that performs analyses of antibiotic residues in the environment and in foodstuffs." ¹²

No further evidence identified on the Ministry of Public Health website. ¹³

A July 2023 article from CIRAD, a French agricultural research organization, states that " a team from CIRAD, working with the Institut Pasteur in Madagascar, conducted a pilot study in the area around Antananarivo. The study used Escherichia coli strains resistant to beta-lactamase antibiotics…and sought to detect them in a range of hosts (humans, pigs, chicken, ducks, cattle, etc) and in the environment (drinking and irrigation water)." ¹⁴

1.1.2 Antimicrobial control

1.1.2a National law(s) requiring prescription for antibiotic use (humans)

Score: 50

National legislation requiring prescriptions for the sale of antibiotics to humans is in place in Madagascar; however, multiple sources provide evidence of significant and widespread gaps in enforcement.

The principal law governing the sale of medications is Law No. 2011-02, also known as the Health Code. This legislation requires a prescription for dispensing all medications intended for human use, but does not specifically mention antibiotics. ¹⁵

According to a 2020 article in the African Journal of Emergency Medicine titled, "Antimicrobial resistance situation in Madagascar," regulations prohibiting the dispensing of non-prescription drugs exist, but they are not enforced. The article states that, importantly, "most of the antibiotics can be purchased without medical prescription". ¹⁶

No further evidence identified on the Ministry of Public Health website. ¹⁷

1.1.2b National law(s) requiring prescription for antibiotic use (animals)

Score: 0

There is no evidence of a specific, enforced national law or regulation in Madagascar that requires a prescription for the sale or use of antibiotics in animals.

According to a 2020 study published in Frontiers in Veterinary Science, "Perception of Drug Vendors and Pig and Poultry Farmers of Antimicrobial Use, and Its Alternatives, in Madagascar," self-medication of animals with antibiotics is a common practice among breeders in the country. The study found that this practice is "facilitated by easy access to drugs (sold in veterinary practices, drug depots and also in markets) and because a prescription was not always required." ¹⁸

No further evidence identified on the Ministry of Public Health website or in Law No. 2011-02, also known as the Health Code. ¹⁹²⁰

1.2 Zoonotic disease

1.2.1 National planning for zoonotic diseases/pathogens

1.2.1a Laws/plans on zoonotic disease

Score: 0

There is very little evidence that Madagascar has national strategies, although there are some reporting systems in place for zoonotic diseases. There is no evidence that there are national legislation, plans, or equivalent strategy documents for zoonotic disease prioritzation, detection and reporting.

A central element of Madagascar's current strategy is the adoption of a One Health approach, which was formalized in 2023 with the establishment of a national One Health Platform to improve coordination between human, animal, and environmental health sectors. A major step towards consolidating this strategy occurred in October 2024, when the Food and Agriculture Organization (FAO) supported a national evaluation of the country's animal and zoonotic disease surveillance system. According to the FAO's report, "Madagascar strengthens its animal and zoonotic disease surveillance system through the Surveillance Evaluation Tool (SET) with support from FAO" (October 2024), the results of this evaluation will serve as the "foundation for the development of a tailored national action plan". For detection and reporting, Madagascar relies on a national surveillance network called MADSUR, which is "well integrated" at the national level. The evaluation mentions several areas for improvement, including "the national laboratory network, the legislative framework, surveillance methods as well as a lack of material, financial, and human resources." ²¹

The Health Sector Development Plan (PDSS) 2015-2019 prioritizes several zoonotic diseases by giving them specific attention within Section 2.2.2.3.4, "Maladies émergentes et ré-émergentes et maladies tropicales négligées" (Emerging and Re-emerging Diseases and Neglected Tropical Diseases), on pages 41-44. The prioritized pathogens include plague, cysticercosis, rabies, and viral threats such as avian influenza, Ebola, and arboviruses. This plan describes a national epidemiological surveillance system in Section 2.1.3.1 (page 13), which includes an early warning system for the real-time detection of epidemics. It specifically mentions that the Institut Pasteur de Madagascar (IPM) is responsible for confirming cases of plague, demonstrating a clear detection pathway (page 41). The plan explicitly defines plague as a disease with mandatory reporting ("maladie transmissible à déclaration obligatoire") on page 41. A diagram of the health information reporting circuit is also provided in Figure 1 on page 13, showing the flow of information from local health centers to the central level. ²²

No further evidence identified on the Ministry of Public Health website or in Law No. 2011-02, also known as the Health Code. ²³²⁴

1.2.1b Laws/plans on zoonotic disease spillover from animals to humans

Score: 0

There is no evidence that Madagascar has national legislation which include measures for risk identification and reduction for zoonotic disease spillover events from animals to humans.

There is no document relating to zoonotic disease spillovers on the websites and Facebook pages of the Ministry of Public Health or the Ministry of Agriculture, Animal Husbandry and Fisheries. ²⁵²⁶²⁷²⁸

According to a Food and Agriculture Organization (FAO) report, "Madagascar strengthens its animal and zoonotic disease surveillance system through the Surveillance Evaluation Tool (SET) with support from FAO" (October 2024), the country is actively working to improve its ability to counter health threats at the human-animal-environment interface. This initiative, which builds upon the formal establishment of a national One Health Platform in 2023, is designed to lead to a "tailored national action plan" to make the surveillance system more robust. ²⁹

1.2.1c Laws/plans for surveillance & control of multiple zoonotic pathogens

Score: 100

Madagascar has a 2019 strategic plan that accounts for the surveillance and control of multiple zoonotic pathogens of public health concern, although as per a 2024 a national plan for zoonotic disease is in the process of being formulated.

In April 2024, the Food and Agriculture Organization of the United Nations (FAO) launched the "Strengthening Animal Health Capacity and One Health to Prevent and Mitigate Risks and Threats Related to Zoonotic Diseases, Food Safety and Antimicrobial Resistance (AMR) in Madagascar" project, which will be implemented by the FAO Emergency Centre for Transboundary Animal Diseases (ECTAD). "The aim of this project is to provide support to Madagascar's animal health services to meet the requirements of the International Health Regulations (IHR 2005) due to Madagascar facing several emerging and re-emerging zoonotic diseases." "Funded by the United States Agency for International Development (USAID), FAO will collaborate with several ministries including Public Health, Agriculture and Livestock, Environment and Sustainable Development, Fisheries and the Blue Economy, and Education and Scientific Research." ³⁵

1.2.1d Cross-ministerial department/agency/unit for zoonotic disease

Score: 100

Madagascar has a formally established multi-sectoral coordinating mechanism dedicated to zoonotic diseases that functions across various ministries. This body is the Plateforme Nationale "Une Seule Santé" (National "One Health" Platform).

This platform was officially created by Decree N°2023-1356, signed on October 11, 2023. The decree establishes the platform as the primary national body for implementing the "One Health" approach, which integrates human, animal, and environmental health sectors to address health threats, including zoonotic diseases. Article 5 specifies that the platform aims to "strengthen the national coordination of multisectoral activities, in order to optimize prevention, preparedness, and response to diseases and health events." Article 6 further defines its mission as coordinating all national activities that require the involvement of at least two of the "One Health" sectors (human, animal, and environmental health). Article 7 outlines a formal structure consisting of a steering committee for decision-making, a multisectoral technical coordination committee, and a permanent secretariat. ³⁷

1.2.1e Presence of One Health strategic plan

Score: 0

While there is no evidence of a standalone One Health strategy for Madagascar, the country formalized its national One Health Platform in 2023.³⁸

1.2.2 Surveillance systems for zoonotic diseases/pathogens

1.2.2a Surveillance/reporting mechanism for zoonotic disease for livestock owners

Score: 100

Madagascar has a national mechanism for owners of livestock to report on disease surveillance to a central government agency, and this mechanism is mandatory.

The Law No. 2006-030 on Livestock in Madagascar establishes the legal framework for animal disease surveillance. Article 57 of this law explicitly states that any owner or person in charge of an animal suspected of being infected with or having died from a contagious disease is required to immediately notify the nearest agents of the veterinary administration or the sanitary veterinarian. This initial report from the owner triggers an official process where the veterinary agent makes a formal declaration to the local and central administration. ³⁹

Decree No. 2018-591 regulating official controls of animals and animal-origin products in Madagascar was passed as an addendum to the law. The decree designates the Directorate in charge of Veterinary Services within the Ministry of Agriculture and Livestock as the unique competent veterinary authority at the national level (Art. 5). Livestock owners and operators (“opérateurs”) are subject to mandatory controls and reporting obligations, and must comply with sanitary rules and provide information to the veterinary authority regarding their animals, products, and facilities (Arts. 29, 30, 31, 34). ⁴⁰

1.2.2b Laws/regulations on data confidentiality to protect livestock owners

Score: 0

There is no specific legislation or regulation that explicitly safeguards the confidentiality of information generated through surveillance activities for animal owners in Madagascar.

Law No. 2014-038 on the Protection of Personal Data provides a broad legal framework for confidentiality. The law applies to any information concerning an identified or identifiable natural person. Article 15 of this law establishes a security obligation, requiring the person or entity responsible for processing data to take all necessary precautions to preserve its security and, notably, to prevent it from being disclosed to unauthorized third parties. ⁴¹ However, it does not specifically cover data collected from animal monitoring activities.

The "The Law No. 2006-030 on Livestock in Madagascar " establishes a professional ethical framework as the primary, albeit indirect, safeguard. Article 38 of this law mandates the creation of a Veterinary Code of Ethics to be upheld by the National Order of Veterinary Doctors of Madagascar. ⁴² Furthermore, the training manual for Community Animal Health Agents (ACSA) outlines a reporting process where surveillance information, including the owner's name, is shared with multiple administrative and veterinary authorities, such as the local mayor, chief of the quarter, and the veterinary services. The manual does not mention any specific measures or protocols to ensure the confidentiality of the owner's information within this reporting chain. ⁴³

1.2.2c Wildlife zoonotic disease surveillance

Score: 100

Madagascar conducts surveillance of zoonotic diseases in wildlife, poultry, and livestock through a combination of a national animal disease surveillance network, targeted research projects, and an overarching "One Health" strategy.

The surveillance of livestock and poultry is the most formalized component, managed primarily through the Madagascar Diseases Animal Surveillance (MADSUR) network. According to a 2024 report from the Food and Agriculture Organization (FAO), "Madagascar strengthens its animal and zoonotic disease surveillance system through the Surveillance Evaluation Tool (SET) with support from FAO," MADSUR is a well-integrated national system for monitoring animal diseases. No further detail about MADSUR is mentioned. ⁴⁴

The inclusion of poultry in these surveillance efforts is confirmed by the participation of the Interprofession avicole de Madagascar (poultry professional body) in national One Health project discussions, as noted in an April 2024 FAO report announcing the launch of the "Strengthening Animal Health Capacity and One Health to Prevent and Mitigate Risks and Threats Related to Zoonotic Diseases, Food Safety and Antimicrobial Resistance (AMR) in Madagascar" project, which will be implemented by the FAO Emergency Centre for Transboundary Animal Diseases (ECTAD). ⁴⁵

Launched in April 2023 under the international PREZODE (Preventing ZOonotic Disease Emergence) initiative, the Project AfriCam Madagascar (Wildlife & Emerging Threats) is the primary program dedicating resources specifically to wildlife surveillance. It targets the detection of emerging zoonoses in wild fauna to prevent spillover events and monitors priority pathogens including Rift Valley Fever, Rabies, and wildlife-borne viruses like coronaviruses and hantaviruses. ⁴⁶

1.2.3 International reporting of animal disease outbreaks

1.2.3a Annual reporting to OIE on zoonotic disease incidence

Score: 100

There is publicly available evidence of a mechanism for Madagascar to report notifiable diseases to the World Organisation for Animal Health (WOAH).

Publicly accessible data on WOAH's regional website for Africa shows that Madagascar submits Immediate Notifications regarding disease outbreaks. For instance, the webpage for "Immediate notifications in Africa" lists a report from Madagascar for Rift Valley fever submitted on April 2, 2021, although the link is not currently operational. ⁴⁷

1.2.4 Animal health workforce

1.2.4a Number of veterinarians per 100,000 people

Score: 2.74

1.2.4b Number of veterinary para-professionals per 100,000 people

Score: 7.86

1.2.5 Private sector and zoonotic disease

1.2.5a Inclusion of private sector in national plan/law on zoonotic disease

Score: 0

There is no evidence that Madagascar’s national plans and strategic frameworks for zoonotic disease control include mechanisms for working with the private sector.

1.3 Biosecurity

1.3.1 Whole-of-government biosecurity systems

1.3.1a Updated national records of especially dangerous pathogen/toxin inventories

Score: 0

There is no evidence that Madagascar has a comprehensive national record, updated within the past five years, detailing the facilities where especially dangerous pathogens and toxins are stored, their specific inventories, or the inventory management systems in use.

According to the 2017 WHO Joint External Evaluation for Madagascar, laboratories handling any pathogens are recorded owing to the requirement for ministerial authorisation. However, there is no evidence that records of the specific pathogens being used or stored in these establishments is maintained. ⁵²

The Institut Pasteur de Madagascar (IPM), a central public health laboratory, has reported significant infrastructure upgrades. The "Rapport d'activités 2021" (2021 Activity Report) for IPM details the acquisition of a new incinerator for waste elimination and the construction of a new storage facility to reinforce its storage capabilities. However, there is no mention the creation or maintenance of a specific inventory of stored pathogens. ⁵³

There is no document relating to dangerous pathogen records on the website or Facebook pages of the Ministry of Public Health. ⁵⁴⁵⁵

The Biological Weapons Convention Implementation Measures database for Madagascar does not list any law or ordinance requiring the existence of such a record. Madagascar has submitted BWC CBMs in 2012, 2017, 2019, 2022 and 2023. These are not publicly available. ⁵⁶ The VERTIC database does not include recent legislation or documents from Madagascar referring to records of the facilities in which especially dangerous pathogens and toxins are stored or processed. ⁵⁷

1.3.1b Biosecurity laws on facility security for especially dangerous pathogens

Score: 0

There is no evidence that Madagascar has in place legislation and/or regulations related to biosecurity which address requirements such as physical containment, operation practices, failure reporting systems, and/or cybersecurity of facilities in which especially dangerous pathogens and toxins are stored or processed.

According to the 2017 WHO Joint External Evaluation for Madagascar, the country lacks a national legal and regulatory framework for biosecurity and has not adopted a multi-sectoral approach involving health and security agencies. ⁵⁸ There is no evidence that the situation has been rectified since 2017 on the website or Facebook page of the Ministry of Public Health. ⁵⁹⁶⁰

The Biological Weapons Convention Implementation Measures database for Madagascar does not list any law or ordinance requiring the existence of such a record. Madagascar has submitted BWC CBMs in 2012, 2017, 2019, 2022 and 2023. These are not publicly available. ⁶¹ The VERTIC database does not include legislation or documents from Madagascar referring to biosecurity which address requirements such as physical containment, operation practices, failure reporting systems, and/or cybersecurity of facilities in which especially dangerous pathogens and toxins are stored or processed. ⁶²

1.3.1c Agency for enforcement of biosecurity laws/regulations

Score: 0

Madagascar does not have legislation or regulations related to biosecurity, or an agency responsible for the subject.

According to the 2017 WHO Joint External Evaluation for Madagascar, the country lacks a national legal and regulatory framework for biosecurity, and has not adopted a multi-sectoral approach involving health and security agencies. The assessment does not mention the existence of an entity charged with overseeing biosecurity, and notes a lack of uniform practice, ranging from strong practice at the non-governmental Pasteur Institute of Madagascar (which serves as a national reference laboratory) to inadequate practice at the main public hospital and veterinary laboratories. ⁶³ There is no evidence that the situation has been rectified since 2017 on the website or Facebook page of the Ministry of Public Health or on the VERTIC database. ⁶⁴⁶⁵⁶⁶

The Biological Weapons Convention Implementation Measures database for Madagascar does not list any pertinent law or ordinance. Madagascar has submitted BWC CBMs in 2012, 2017, 2019, 2022 and 2023. These are not publicly available. ⁶⁷

1.3.1d Consolidation of especially dangerous pathogens into minimum # of facilities

Score: 0

There is no evidence that Madagascar has taken action to consolidate its inventories of especially dangerous pathogens and toxins into a minimum number of facilities. Madagascar does not have a record of inventories of dangerous pathogens and toxins.

According to the 2017 WHO Joint External Evaluation for Madagascar, laboratories handling dangerous pathogens are recorded owing to the requirement for ministerial authorisation, but there is no record of the pathogens being used or stored in these establishments."As a result of the weak laboratory network and the way that biological sample circuits are organised, especially dangerous pathogens tend to converge towards two non-governmental laboratories: the Pasteur Institute of Madagascar (PIM) and the Charles Mérieux Infectiology Centre (CMIC)." ⁶⁸

There is no evidence of efforts to consolidate inventories since 2017 on the website or Facebook page of the Ministry of Public Health or on the VERTIC database. ⁶⁹⁷⁰⁷¹

1.3.1e Capacity to conduct tests for anthrax/Ebola without culturing live pathogens

Score: 100

There is public evidence demonstrating that Madagascar has the in-country capacity to conduct Polymerase Chain Reaction (PCR)–based diagnostic testing for certain high-priority pathogens, which would preclude the need for culturing a live virus in the case of Ebola. This capacity is primarily centered at the Institut Pasteur de Madagascar (IPM).

According to the 2017 WHO Joint External Evaluation for Madagascar, the only institute in the country known to practise international biosecurity standards and to have a Biosafety Level 3 facility is the Pasteur Institute of Madagascar (PIM), a non governmental institute which serves as national reference laboratory. PIM is one of two laboratories to which dangerous pathogens are channelled, the other being the Charles Mérieux Infectiology Centre. ⁷³

The "Rapport d'activités 2021" (2021 Activity Report) of the Institut Pasteur de Madagascar confirms that PIM conducts PCR-based detection for Ebola-related viruses using pan-PCR and sequencing. ⁷⁴

1.3.2 Biosecurity training and practices

1.3.2a Biosecurity training using a standardised, required approach

Score: 0

There is no evidence that Madagascar has a nationally mandated, standardized biosecurity training requirement for all personnel working with dangerous pathogens. However, there is significant public evidence of internationally supported, curriculum-based training programs and workshops, including train-the-trainer initiatives, aimed at building this capacity within the country.

According to the World Organisation for Animal Health (WOAH), Madagascar has been a beneficiary of targeted biosafety and biosecurity training. In a report from October 2024, WOAH detailed a comprehensive training workshop held from September 25-29, 2023, for personnel from animal health laboratories in Madagascar. This workshop, part of the "Fortifying Institutional Resilience Against Biological Threats (FIRABioT) Project," provided participants with skills on implementing a biorisk management system in accordance with WOAH and other international standards. The training utilized lectures, tabletop exercises, and demonstrations. The report notes that participants were encouraged to "cascade the training". ⁷⁵

Further evidence of standardized training comes from the "East Africa Bio-risk Management (BRM) Network Train-the-Trainer (TOT) program," sponsored by the US Defense Threat Reduction Agency (DTRA) and implemented by Sandia National Laboratories. The foundational session of this program's second cohort was held in Antananarivo, Madagascar, in April 2024. This initiative is explicitly designed to create a network of trainers across East Africa, including Madagascar. Participants in the program gain access to the "Global Biorisk Management Curriculum (GBRMC)," a repository of over 40 courses centered on best practices in biosafety and biosecurity. ⁷⁶

No further evidence identified on the website or Facebook page of the Ministry of Public Health or on the VERTIC database. ⁷⁷⁷⁸⁷⁹

1.3.3 Personnel vetting: regulating access to sensitive locations

1.3.3a Personnel checks for permission to access to especially dangerous pathogens

Score: 0

There is no public evidence to suggest that Madagascar has regulations or licensing conditions that specifically require personnel with access to especially dangerous pathogens to undergo drug testing, background checks, or psychological and mental fitness evaluations.

The 2017 WHO Joint External Evaluation for Madagascar states that ministerial authorisation is required for laboratories to function (though fails to clarify whether this is for all laboratories or for those handling dangerous pathogens). ⁸⁰

There is no evidence on background checks on the website or Facebook page of the Ministry of Public Health, on the VERTIC database, or the Biological Weapons Convention National Implementation Measures Database. ⁸¹⁸²⁸³⁸⁴

1.3.4 Transportation security

1.3.4a National transport regulations for Category A and B infectious substances

Score: 0

There is no evidence that Madagascar has publicly-available information on national regulations on the safe and secure transport of infectious substances, except for a reference to international standards in the case of air travel regulations.

The 2017 WHO Joint External Evaluation for Madagascar states that international transport of samples is not a problem thanks to initiatives by the country's most competent laboratories, but international rules are not applied in domestic transport, whether land or air. ⁸⁵

The civil aviation authority's 'Madagascar Aeronautical Regulations relating to the technical conditions for operating an aircraft by a public air transport company', updated in 2024, states that operators must comply with the provisions of the "Instructions Techniques" (Technical Instructions). The regulation reiterates that dangerous goods must be classified, documented, packaged, and prepared for transport in accordance with the ICAO Technical Instructions (Doc 9284-AN/905) and explicitly defines the "Instructions Techniques" as the latest edition of the (Doc 9284-AN/905), which is the official ICAO document detailing the transport of dangerous goods, including the classification of infectious substances into Category A and Category B. ⁸⁶

No further evidence identified on the website or Facebook page of the Ministry of Public Health, on the VERTIC database, or the Biological Weapons Convention National Implementation Measures Database. ⁸⁷⁸⁸⁸⁹⁹⁰

1.3.5 Cross-border transfer and end-user screening

1.3.5a Laws/regulations on cross-border transfer and end-user screening

Score: 0

There is no evidence of a single, comprehensive law or regulation specifically designed to oversee the cross-border transfer and end-user screening of especially dangerous pathogens, toxins, or pathogens with pandemic potential.

The 2017 WHO Joint External Evaluation for Madagascar notes that Madagascar lacks biosecurity legislation, but the country's leading (non-governmental) laboratories have established systems meeting international standards for international transfer of biological samples. ⁹¹

The civil aviation authority's 'Madagascar Aeronautical Regulations relating to the technical conditions for operating an aircraft by a public air transport company', updated in 2024, establishes that transport of dangerous substances must adhere to international standards, but does not lay out any system for authorizing transfers based on end-user screening or the specific risk posed by the pathogen itself. ⁹²

1.4 Biosafety

1.4.1 Whole-of-government biosafety systems

1.4.1a Biosafety laws/regulations

Score: 0

Madagascar does not have a single, comprehensive national biosafety law that has been formally enacted and implemented. However, a draft law exists, and the country is actively participating in international initiatives to establish a more robust legal framework.

According to a November 2023 announcement regarding the "Strengthening of the National Biosafety Framework (SINBF) project," Madagascar is one of three southern African countries receiving support to reinforce its national framework for implementing the Cartagena Protocol on Biosafety. ⁹⁷

This is further substantiated by a March 2021 report from the Global Environment Facility (GEF), which noted that while other nations in the project were at different stages, Madagascar had a "draft version [of a biosafety law] that is in need of review". ⁹⁸

No further evidence of a biosafety law identified on the website or Facebook page of the Ministry of Public Health, on the VERTIC database, or the Biological Weapons Convention National Implementation Measures Database. ⁹⁹¹⁰⁰¹⁰¹¹⁰²

1.4.1b Agency for enforcement of biosafety laws/regulations

Score: 0

1.4.2 Biosafety training and practices

1.4.2a Biosafety training using a standardised, required approach

Score: 0

There is no evidence that Madagascar has a nationally mandated, standardized biosafety training requirement for all personnel working with dangerous pathogens. However, there is significant public evidence of internationally supported, curriculum-based training programs and workshops, including train-the-trainer initiatives, aimed at building this capacity within the country.

No further evidence identified on the website or Facebook page of the Ministry of Public Health or on the VERTIC database. ¹¹¹¹¹²¹¹³

1.5 Dual-use research and culture of responsible science

1.5.1 Oversight of dual-use research

1.5.1a Evidence of national assessment of dual-use research

Score: 0

There is no publicly available evidence that Madagascar has conducted a formal, national-level assessment to identify and inventory all ongoing research involving especially dangerous pathogens, toxins, or dual-use research.

According to information submitted to the Biological Weapons Convention (BWC) Implementation Support Unit, Madagascar has developed some measures related to the oversight of life sciences research. This is reflected in an order that designates a national authority and establishes a technical committee for the implementation of the BWC. However, there are no details of a specific, comprehensive national assessment of ongoing research projects or a formal process for reviewing dual-use potential. ¹¹⁴

No further evidence identified on the website or Facebook page of the Ministry of Public Health or on the VERTIC database. ¹¹⁵¹¹⁶¹¹⁷

1.5.1b National law/regulation on oversight of dual-use research

Score: 0

There is no single, comprehensive piece of legislation in Madagascar that specifically requires and details the oversight of research on especially dangerous pathogens, toxins, or dual-use research. However, the country has developed some legal measures as part of its commitment to the Biological Weapons Convention (BWC) and has a draft biosafety law in development that points toward an emerging regulatory framework.

According to a workshop summary note from the United Nations Office for Disarmament Affairs (UNODA), a workshop was held in Antananarivo from August 12-14, 2024, to strengthen national legislation on biological weapons. This event, co-organized by the Republic of Madagascar, UNODA, and the European Union, involved representatives from numerous Malagasy ministries and the Institut Pasteur de Madagascar. A key objective was to review and finalize a "draft law on biological weapons and toxins" and a "draft decree establishing a mechanism for the implementation of the BWC" that had been prepared by Madagascar in May 2024. ¹¹⁸

Information submitted by Madagascar to the BWC Implementation Support Unit confirms that the country has developed some measures related to the oversight of life sciences research, which are reflected in a formal Order No. 7805/2016. ¹¹⁹ However, this order has no pertinent requirements on oversight of esearch on especially dangerous pathogens, toxins, or dual-use research. ¹²⁰

No further evidence identified on the website or Facebook page of the Ministry of Public Health or on the VERTIC database. ¹²¹¹²²¹²³

1.5.1c Existence of agency responsible for oversight of dual-use research

Score: 0

Information submitted by Madagascar to the BWC Implementation Support Unit confirms that the country has developed some measures related to the oversight of life sciences research, which are reflected in a formal Order No. 7805/2016. ¹²⁵ However, this order has no pertinent requirements on oversight of esearch on especially dangerous pathogens, toxins, or dual-use research. ¹²⁶

No further evidence identified on the website or Facebook page of the Ministry of Public Health or on the VERTIC database. ¹²⁷¹²⁸¹²⁹

1.5.2 Screening requirements for providers of genetic material

1.5.2a Requirement to screen synthesised DNA against list prior to sale

Score: 0

There is no evidence of any legislation or regulation in Madagascar that specifically requires the screening of synthesized DNA (deoxyribonucleic acid) against lists of known pathogens and toxins before it is sold.

The most relevant legislation in Madagascar concerning genetic material is Decree N° 2017-066 on Regulating Access and Sharing of Benefits resulting from the Utilisation of Genetic Resources. This decree operationalizes the Nagoya Protocol by establishing a legal framework for Access and Benefit-Sharing (ABS). Its primary focus is to ensure that the country and its local communities receive fair and equitable benefits from the use of Madagascar's natural genetic resources and associated traditional knowledge. The law requires any person or organization seeking to use these resources for research or commercial purposes to obtain Prior Informed Consent (PIC) and establish Mutually Agreed Terms (MAT). However, the scope of this decree is limited to the access and use of naturally occurring genetic resources. It does not address the de novo synthesis of DNA from a sequence or impose any biosecurity screening requirements on providers of synthetic DNA. ¹³⁰

1.6 Immunization

1.6.1 Vaccination rates

1.6.1a Immunization rate for humans (measles/MCV2)

Score: 0

1.6.1b Availability of vaccination figures for livestock (FMD) through OIE database

Score: 0

Madagascar reports animal disease information to the World Organisation for Animal Health (WOAH, formerly OIE), specific official figures for foot-and-mouth disease (FMD) vaccination are not publicly available through the WOAH's databases because the country is officially recognized as being free of FMD without vaccination. A February 2025 "Report of the Meeting of the WOAH Scientific Commission for Animal Diseases” acknowledged "Madagascar’s efforts to maintain its FMD-free status, including progress in expanding the electronic identification system for small ruminants and collecting a significant amount of serum samples for testing." ¹³⁵

1.6.1c Equitablenature of national immunization strategy/plan

Score: 0

There is evidence that Madagascar has a national immunization strategy that includes plans for equitable distribution and specific strategies to overcome socioeconomic, geographic, and other barriers to vaccination, but the policy document is not publicly available.

According to a July 2024 UNICEF report on "National Immunization Strategy: Analysis of NIS roadmap, costing, budgeting and financing from NIS developed in 2021-2023 ", Madagascar is listed in all "Countries having NIS with financing section and fully developed/finalized". ¹³⁶

The "Targeted Country Assistance Plan for Madagascar (2020)" from Gavi outlines a goal to ensure that the annual EPI operational work plan is informed by equity analysis. This plan is designed to reduce inequities by specifically targeting "children from the most marginalized, most isolated, insecure and vulnerable communities". As per the publication, the national strategy employs the "Reach Every Community" approach and focuses on supporting the 33 priority districts. Specific interventions recommended and utilized in the country include outreach campaigns like National Immunization Days (NIDs), Subnational Immunization Days (SNIDs), and Vaccination Weeks (VWs), which establish additional vaccination sites and involve vaccinators going directly to homes, schools, and markets. ¹³⁷

In July 2025, Gavi awarded USD 900,000 to MCD Global Health to increase vaccination coverage for hard-to-reach children in 15 districts. ¹³⁸

1.6.1d Vaccine hesitancy and build public trust coverage in vaccines in national immunization strategy/plans

Score: 0

There is evidence that Madagascar's operational plans include specific, publicly documented measures to address vaccine hesitancy and build public trust in vaccines, but the policy document for national immunization strategy is not publicly available to verify whether it includes similar measures.

According to reports on recent polio vaccination campaigns, a key to their success was the implementation of a robust Social and Behavior Change (SBC) strategy developed by the Ministry of Public Health with support from partners like UNICEF. This strategy directly addresses public trust by engaging a wide range of local stakeholders. For instance, during a 2024 polio campaign, symbolic vaccination events were held in classrooms to build confidence among parents and the community. ¹³⁹

The polio SBC strategy utilized door-to-door visits by social mobilizers, which accounted for informing 65% of parents about the campaign. Furthermore, when refusals were encountered, particularly in some private schools, local refusal management committees were activated to mitigate the issues through direct engagement and dialogue. This approach was supplemented by outreach during weekends at households and places of worship to further minimize refusal rates. These campaigns also found that engaging women, particularly mothers, as frontline actors significantly boosted vaccine acceptance, as they were effective in convincing their peers and family members of the importance of vaccination. ¹⁴⁰

1.6.1e National advisory group for immunization strategy/plan

Score: 100

Madagascar has established a national advisory group to provide technical guidance on its immunization strategy. This body is known as the National Immunization Technical Advisory Group (NITAG).

A November 2023 article from the International Vaccine Institute (IVI) concerning a typhoid conjugate vaccine (TCV) project in Madagascar explicitly states that the project team will "work closely with Madagascar’s recently formed National Immunization Technical Advisory Group to accelerate TCV introduction and apply for support from Gavi to roll out TCV nationwide". ¹⁴¹

A Gavi Programme Audit Report from July 2023 noted that "Delays in the operationalisation of the Technical Advisory Group for Immunisation also impacted on the EPI Directorate’s effectiveness". ¹⁴²

Madagascar has established a national advisory group to provide technical guidance on its immunization strategy. This body is known as the National Immunization Technical Advisory Group (NITAG). The WHO's NITAG Resource Center map confirms that Madagascar has a declared NITAG. ¹⁴³

1.6.1f Presence of an immunization programme for influenza

Score: 0

Madagascar does not have a national immunization program for influenza.

According to data from the World Health Organization (WHO) updated for 2023 and 2024, Madagascar is listed as a country that has not introduced the seasonal influenza vaccine into its national immunization program. ¹⁴⁴

No further evidence identified on the website or Facebook page of the Ministry of Public Health ¹⁴⁵¹⁴⁶

1.7 Climate change adaptation and vector transmission

1.7.1 Health system resilience

1.7.1a Strategy/plan for resilience of health system

Score: 100

There is clear evidence that Madagascar has a national strategy and concrete plans to strengthen the resilience of its health system to climate change and climate-sensitive infectious diseases, as outlined in the National Climate Change Adaptation Plan (PNA) 2021.

The PNA explicitly identifies the health sector as “climato-sensible”, noting that rising temperatures are increasing the distribution of disease vectors such as malaria. Strategic priorities include training health workers on climate-related health risks and adaptation, building climate-resilient health infrastructure, and ensuring health services can respond to emergencies and epidemics (pages 60-63). Strategic Priority 2 involves public awareness, community training, and strengthening local health services to respond to climate-driven epidemics and environmental health threats. Programme National 6, Pages 94–95, 113, recognizes that climate change increases the risk of propagation of climate-sensitive diseases and establishes a multi-hazard early warning system (SAP santé multirisques) for health, coordinated with meteorological and disaster management agencies), with indicators on climate-related health outcomes and vulnerable groups. ¹⁴⁷

Early Detection

2.1 Laboratory systems strength and quality

2.1.1 Lab capacity for detecting priority diseases

2.1.1a Capacity of national lab system to conduct 5 or more WHO core tests

Score: 50

There is evidence that Madagascar's national laboratory system, which includes the formal involvement of the non-governmental Pasteur Institute of Madagascar, possesses the capability to conduct at least 5 of the 10 WHO-defined core diagnostic tests. These include PCR testing for influenza, microscopy for mycobacterium tuberculosis (TB), serological testing for HIV, rapid diagnostic tests for malaria, and at least one additional test (potentially virus culture for polio), though this latter test is not explicitly specified.

The 2017 WHO Joint External Evaluation (JEE) for Madagascar documents that the country maintains a public health laboratory network comprising national and regional facilities, with PIM formally integrated at the national level. Madagascar achieved a score of 4 for indicator D.1.1 in this assessment, demonstrating that the laboratory system can perform five or more of the ten core tests (pg. 21).¹⁴⁸

Beyond the JEE, independent sources confirm capacity for at least 4 core tests. Documentation from IPM shows it can conduct PCR diagnostics for influenza and COVID-19, as well as virological diagnosis for polio (specific test method not stated). ¹⁴⁹¹⁵⁰¹⁵¹ IPM's Clinical Biology Centre (CBC) serves as the national reference centre for salmonella, sharing this role with its Food and Environmental Hygiene Laboratory. ¹⁵² The Mycobacteria Unit at IPM functions as the national reference centre for TB, operating biosafety level 3 facilities and performing microscopy-based testing for mycobacterium tuberculosis. ¹⁵³

National and regional reference laboratories for HIV operate under the health ministry and conduct HIV screening using blood samples. ¹⁵⁴

The National Reference Centre for Malaria, operating under the health ministry, performs rapid diagnostic testing for malaria, with such testing widely accessible throughout the country. ¹⁵⁵

No evidence was found indicating that Madagascar has established country-specific core tests, based on review of the health ministry's website and searches of WHO reports and media coverage. ¹⁵⁶

2.1.1b Plan to conduct testing during a public health emergency

Score: 0

There is no evidence that Madagascar has a national plan for conducting testing during a public health emergency which includes considerations for testing for novel pathogens, or defining goals for testing. According to the 2017 WHO Joint External Evaluation Madagascar had reacted to several crises in the past 5 years in a coordinated manner, based on existing contingency plans. ¹⁵⁷ On the website of the 'Center for the prevention and management of emergencies (cellule de prévention et gestion des urgences CPGU)' there are several laws and decrees on emergency reactions ¹⁵⁸, namely 'Law No. 2015-031 on national policy for the management of risks and catastrophes', the 'National Strategy for the Management of risks and catastrophes 2016-2030' , 'Decree No. 2019-1954 on the modalities of application of the law no. 35 2015-031 on national policy for the management of risks and catastrophes' and 'Decree No. 2019 – 1958 on the organisation, mode of functioning and scope of the National Office for the management of risks and catastrophes (BNGRC)'. ¹⁵⁹¹⁶⁰¹⁶¹¹⁶². None of these mention testing for novel pathogens, scaling capacity, or goals for testing. ¹⁶³¹⁶⁴¹⁶⁵¹⁶⁶ As a reponse to the on going public health crisis due to COVID-19, the government of Madagascar published the “Multisectoral Emergency Plan (Plan Multisectoriel D'Urgence – PMDU)” in July 2020. This plan does not mention testing for novel pathogens, or goals for testing, but does mention upscaling testing capacities, at least for COVID-19. ¹⁶⁷.

The"Madagascar Health Emergency Appeal 2023" lists the "development and implementation of a preparedness and response plan at the regional and district level" as a key activity, indicating planning was ongoing. ¹⁶⁸

The Pandemic Preparedness and Basic Health Services Delivery Project strongly supports implementing the National Action Plan for Health Security (NAPHS) 2020-2024 and the National Strategic Plan for Public Health Surveillance. These national documents guide goals for addressing emerging and re-emerging infectious diseases and explicitly include strengthening both human and animal health laboratory networks (24 laboratories targeted) to enhance the Laboratory Quality System to a "Demonstrated capacity. ¹⁶⁹ Madagascar has a National Action Plan on Health Security, but it does not seem to be publicly available. No evidence was found on the official websites of Madagascar’s Ministry of Public Health. ¹⁷⁰

2.1.2 Laboratory quality systems

2.1.2a Existence of an accredited national lab serving as a reference facility

Score: 100

There is currently at least one accredited national reference laboratory in Madagascar under ISO 15189 standards.

The Clinical Biology Center (Centre de Biologie Clinique, CBC) at the Institut Pasteur de Madagascar holds COFRAC accreditation (certificate n° 8-4166) according to the NF EN ISO 15189 standard since December 2018 [Institut Pasteur de Madagascar, 2025]. ¹⁷¹ The Institut Pasteur de Madagascar (Centre de Biologie Clinique) is accredited by COFRAC (Comité Français d'Accréditation) got ISO 15189:2022 accreditation in October 2024. ¹⁷²

No evidence was found to indicate that any national laboratory in Madagascar holds CLIA certification or similar U.S.-based accreditation. Ministry of Public Health publications and the World Health Organization’s Joint External Evaluation reports do not reference CLIA or equivalent certifications for Malagasy laboratories. ¹⁷³ ¹⁷⁴

2.1.2b External quality assurance of a national lab serving as a reference facility

Score: 100

Madagascar's national reference laboratories in the Pasteur Institute of Madagascar (IPM) are accredited in part and IPM's reference laboratory for salmonella is accredited. IPM's Virology Unit is recognised by the World Health Organisation (WHO) as the national reference laboratory for influenza and polio.¹⁷⁵¹⁷⁶ According to IPM's 2018 activity report, it was accredited for French Standard NF EN ISO 15189 V2012 on biomedical laboratory testing in December 2018. ¹⁷⁷ IPM's's Clinical Biology Centre (CBC) is the national reference centre for salmonella, together with PIM's Food and Environmental Hygiene Laboratory (LHAE).¹⁷⁸¹⁷⁹ The CBC is internally audited for compliance with NF EN ISO 15189 V2012 and COFRAC SH REF 02.¹⁸⁰ The CBC was accredited by COFRAC for NF EN ISO 15189 in December 2018, which is a signatory to the European co-operation for Accreditation (EA) Multilateral Agreement. ¹⁸¹ The FEHL has achieved accreditation for NF EN ISO/CEI 17025, on competence of testing and calibration laboratories.¹⁸² PIM's Mycobacteria Unit is the national reference centre for tuberculosis.¹⁸³ There is no evidence that it has accreditation.¹⁸⁴¹⁸⁵ The national reference laboratories for Malaria and HIV/AIDS are under the health ministry.¹⁸⁶¹⁸⁷ They have no online presence and no evidence of accreditation can be found from the health ministry or a wider online search.¹⁸⁸ The domestic standards agency is the Madagascar Standards Bureau.¹⁸⁹

2.2 Laboratory supply chains

2.2.1 Specimen referral and transport system

2.2.1a Nationwide specimen transport system

Score: 0

While components of a specimen transport system are in place and regulated, there is insufficient evidence of a fully established nationwide specimen transport system in Madagascar.

The 2019 national document “Standards and Norms for Medical Analysis Laboratories” (“Normes et Standards en Matière de Laboratoire d’Analyses Médicales”) provides detailed procedures for specimen transport. It specifies that transport must follow written procedures defining maximum transport delays, conservation temperature, and packaging integrity (pp. 22–23, Section IV.3 -Transport and Transmission of Samples [Transport et transmission des échantillons]). The use of indicators to monitor cold chain integrity is recommended, and triple packaging compliant with national and international standards is required for long-distance or inter-laboratory transport. An accompanying file documenting patient identity, specimen type, and provenance must be included, and the sending laboratory must inform the receiving laboratory in advance of shipment and expected arrival (pp. 22–23).
However, the document does not explicitly describe a centralized or fully integrated national specimen transport system under a single authority, nor does it confirm that these practices are uniformly operational across the country. ¹⁹⁰

The 2017 Joint External Evaluation (JEE) similarly found that the system was limited, with specimen transport circuits in place only for specific disease surveillance (e.g., poliomyelitis and plague) and lacking a harmonized, secure, and standardized national system (Indicator D.1.2 – System for Sample Transfer and Transport [Système pour le transfert et le transport d’échantillons], p. 22). ¹⁹¹

No relevant information found on the website of Ministry of Public Health. ¹⁹²

2.2.2 Laboratory cooperation and coordination

2.2.2a Plan to rapidly authorize/license laboratories to scale-up testing during an outbreak

Score: 0

Madagascar does not have a publicly available plan to rapidly authorize or license laboratories to supplement the capacity of the national public health laboratory system to scale-up testing during an outbreak.

The provided National Strategic Plan for the Supply Chain of Health Inputs 2024-2028 (PNSCA) does not contain a plan to rapidly authorize or license laboratories to supplement the capacity of the national public health laboratory system to scale-up testing during an outbreak. The PNSCA's primary objective is to establish an integrated and efficient supply chain for health inputs (such as medicines and reagents) to ensure their availability and quality across Madagascar. The plan outlines strategic activities for strengthening the supply chain, including logistics, financing, and quality control of products (p. 23). ¹⁹³

According to the 2017 Joint External Evaluation (JEE) report of Madagascar, the country possesses a network of public and private laboratories, including 13 national reference laboratories with capabilities to detect priority diseases. The Institut Pasteur of Madagascar (IPM) serves as the main reference laboratory with high biosafety standards. However, the report highlights the absence of a national policy or strategy governing laboratories, including lacking mechanisms for the rapid authorization or licensing of additional laboratories during health emergencies (p. 21-23, sections "Système national de laboratoires" and "Analyses en laboratoire"). The JEE assigns a low score (1 out of 5) to the system for the transfer and transport of samples, and the quality management system for laboratories also scores low, indicating challenges in scalability and coordination (p. 22-23) ¹⁹⁴. Furthermore, there is no indication in the report that Madagascar has formalized procedures or plans to rapidly license or authorize external (e.g., private or other non-public) laboratories to supplement national capacity during outbreaks. Efforts focus on strengthening current laboratory capacities, establishing a national laboratory network, and improving sample transport and quality assurance but without specifying emergency surge mechanisms (p. 21-24). Additionally, the report recommends drafting and implementing a comprehensive laboratory policy and establishing formal coordination mechanisms between human and animal health laboratories to bolster integrated response but does not mention any rapid licensing frameworks (p. 23). No evidence was found in the report or associated references indicating the existence of an operational plan or legal framework for the rapid authorization and licensing of laboratories to scale up testing during outbreaks in Madagascar (p. 21-24, sections "Système national de laboratoires", "Analyses en laboratoire", and "Transfert d’échantillons"). ¹⁹⁵

No relevant evidence was identified on the websites of Ministry of Public Health, Ministry of Environment and Sustainable Development or the Institut Pasteur of Madagascar. ¹⁹⁶¹⁹⁷¹⁹⁸

2.3 Real-time surveillance and reporting

2.3.1 Indicator and event-based surveillance and reporting systems

2.3.1a Evidence of ongoing event-based and indicator-based surveillance and analysis

Score: 50

There is evidence that Madagascar is conducting ongoing event-based surveillance (EBS) for infectious diseases, but not that the data is analysed on a daily basis.

The country's national emergency operations center, the National Operational and Strategic Centre for Epidemiological Surveillance (CNOSSE), receives some EBS data and functions under the Ministry of Public Health's Directorate of Health Monitoring and Epidemiological Surveillance (DVSSE). The 2017 Joint External Evaluation (JEE) confirms the existence of surveillance systems that combine both indicator- and event-based approaches, although it points out gaps in systematic data sharing and multisectoral coordination, especially between human health, animal health, and environmental sectors (p. 26 “Indicator- and Event-Based Surveillance Systems” (Systèmes de surveillance basée sur des indicateurs et de surveillance des événements)). ¹⁹⁹

Evidence of this functional surveillance capacity is then detailed in a June 2025 humanitarian situation UNICEF report describing a severe malaria outbreak. The report explicitly states that "Multiple alerts from the Event-Based Surveillance (EBS) system have flagged a rising number of community deaths," demonstrating an active EBS system. It further confirms the use of a digital indicator-based system by citing the District Health Information Software (DHIS2) as the source for specific data on confirmed malaria infections and for the subsequent analysis of that data, including the calculation of case fatality rates (p. 3). ²⁰⁰

However, routine daily or weekly epidemiological bulletins confirming a national daily analysis cycle for all notifiable diseases were not found on the official websites of the Ministry of Public Health or the Pasteur Institute of Madagascar. ²⁰¹²⁰²

2.3.1b Evidence of a mechanism (such as IHR focal point) for reporting notifiable diseases to the WHO within the set timeline

Score: 100

Madagascar has an established mechanism for reporting notifiable diseases to the World Health Organization (WHO), centered on its International Health Regulations (IHR) National Focal Point (PFN), as confirmed by the 2017 Joint External Evaluation (JEE) and detailed in the 2023-2027 Strategic Plan for Strengthening the Health Information System 2023-2027 (PSRSIS).

As detailed in the 2017 Joint External Evaluation (JEE), Madagascar’s IHR National Focal Point is the Director of the Direction de la Veille Sanitaire et Epidémiologique (DVSSE), who is responsible for timely notification of public health events to WHO. The PFN operates with multisectoral coordination, including veterinary services for reporting animal diseases to the OIE, implementing a One Health approach (p. 28-30, Notification section). Notifications occur using both traditional and electronic methods—SMS and tablets—in selected districts, although challenges exist related to incomplete territorial coverage, delays, and lack of harmonized standard operating procedures (p. 28-31). Broader system strengthening is in progress, with plans to improve coordination between sectors, evaluate PFN functions, and integrate laboratory data more effectively (p. 6-8; p. 26-27). ²⁰³

Madagascar’s 2023-2027 Plan Stratégique de Renforcement du Système d’Information Sanitaire (PSRSIS) explicitly describes the integrated electronic disease surveillance system (Surveillance Épidémiologique Intégrée Electronique, SEIE) using DHIS2 as its backbone. Section 3.2 (p. 20) explains that the SEIE combines electronic reporting tools (ODK, SMS) and physical weekly reports for real-time notification and immediate alert generation of epidemic-prone notifiable diseases. Community-level data collection uses smartphone-based CommCare in ten regions, and paper-based methods in some others, with data automatically fed into the DHIS2 platform. (p. 20, Section 3.2). ²⁰⁴Section 4.1 (p. 22-23) focuses on strategic objectives aligned with IHR requirements, aiming for 95% promptness and completeness of reports across all health facilities, public and private, and establishing a robust early warning system capable of detecting 100% of epidemics and emergencies (p. 22-23). ²⁰⁵

2.3.2 Interoperable, interconnected, electronic real-time reporting systems

2.3.2a Electronic national and sub-national reporting surveillance system

Score: 100

There is evidence that Madagascar operates fully institutionalized electronic reporting surveillance system at both the national and sub-national levels.

Madagascar uses DHIS2 as its national health information system (SNIS) for storing surveillance data ²⁰⁶. DHIS2 is implemented in all 114 health districts for routine data reporting ²⁰⁷. The country’s Health Sector Development Plan (2020–2024) indicates that epidemiological data reporting occurs electronically and/or on paper, with interoperability into DHIS2 ²⁰⁸.
DHIS2 Tracker and Event are used to monitor maternal and other health programs at community and district levels ²⁰⁹. Additionally, an Android-based application allows community health workers to report epidemic alerts electronically, even without continuous internet connectivity ²¹⁰.

2.3.2b Collection of ongoing/real-time lab data by electronic surveillance system

Score: 50

Madagascar's electronic surveillance reporting system collects some real-time laboratory data, but this is limited to sentinel sites, not disaggregated, and does not cover the entire surveillance system.

The surveillance and response system is coordinated by the Directorate of Health Monitoring and Epidemiological Surveillance (DVSSE) under the Ministry of Public Health, which also hosts the country’s public health emergency operations centre. ²¹¹

The Strategic Plan for the Strengthening of the Health Information System 2018-2022 (SIS, Ministry of Public Health, Madagascar). ets out a vision of an "integrated, electronic and functional health information system (HIS) at all levels – health post, district, region, national – ensuring complete, reliable and timely data" (p. 8). Goal 1 sets the migration to digital tools for the notification of priority diseases, with coverage targets ≥90% of health facilities and 100% of districts by 2022 (p. 9). The plan centers on a DHIS2-based e-IDSR platform where all health centres send weekly forms via SMS or web form, with district offices validating and aggregating data before automatic synchronization with the national DVSSE server (p. 18). ²¹² A 2021 WHO country profile confirmed progress, noting that "tablet computers for the electronic integrated disease surveillance system have improved real-time reporting from district to central level," establishing two-way electronic flow between sub-national and national tiers. ²¹³ More recently, Madagascar's Ministry and HISP-UiO announced a DHIS2 platform designed to interoperate with the eIDSR and laboratory systems to enhance electronic data sharing across human and animal health agencies. ²¹⁴

According to the 2017 WHO Joint External Evaluation (JEE) for Madagascar, disease surveillance indicators and events are reported to the DVSSE at the national level by smartphone or tablet in 17 out of 114 health districts, while the electronic reporting system is being progressively expanded to cover additional districts (16). In districts not yet integrated into the electronic system, reports are submitted to the district level by SMS or paper, and subsequently forwarded to the national centre (p. 16). Although the system enables real-time data collection, the JEE assessment notes "weak use of laboratory data for surveillance, except in the case of sentinel surveillance with the existence of biological surveillance sites" (p. 23). ²¹⁵ It recommends the "establishment of a centralised mechanism to integrate the data from clinical case notifications with data from medical analysis laboratories or reference laboratories" (p. 23). ²¹⁶

2.3.3 Wastewater surveillance

2.3.3a National wastewater surveillance programme or initiative

Score: 100

There is evidence that Madagascar has ongoing national environmental or wastewater surveillance programmes.

Following an outbreak of variant type 1 polio in the country in September 2023, a total of 287 cases had been confirmed, including 45 cases of acute flaccid paralysis and 44 community cases, 198 positive environmental surveillance detections in wastewater. Cases were spread across 30 districts in the country’s 13 regions.²¹⁷

In 2025, a new state-of-the-art laboratory was reported as improving Madagascar’s efforts to survey and detect polioviruses and effectively respond to the threat of the disease and protect children from its devastating impacts. Established in 1996, the laboratory has significantly enhanced Madagascar’s ability to rapidly detect poliovirus through both acute flaccid paralysis and environmental surveillance. Between 2022 and 2024, the laboratory detected more than 40 cases of circulating variant poliovirus type 1, enabling immediate and targeted immunization responses (as mentioned above). The efforts played a key role in halting an outbreak of circulating variant poliovirus type 1. In May 2025, Madagascar marked two full years without any new detections of the virus, which meant the outbreak was declared closed after a thorough assessment. ²¹⁸ The handing over of the laboratory to the government marks a major step towards sustainable, country-led polio surveillance and self-sufficiency in managing future outbreaks and ensures strong measures are in place to sustain the country’s polio-free status and contribute to the global goal of ending polio once and for all.

2.4 Surveillance data accessibility and transparency

2.4.1 Coverage and use of electronic health records

2.4.1a Common usage of electronic health records

Score: 50

Electronic Health Records (EHRs) are not yet commonly in use in Madagascar.

According to the National Digital Health Strategy 2023–2027 (Stratégie Nationale en Santé Digitale 2023-2027), the digital health ecosystem in Madagascar remains at an early stage of development, characterized by fragmented pilot initiatives in areas such as telemedicine, mobile health, and electronic health records (Dossier de Santé Électronique). These initiatives are limited in scale and are not yet standardized or widely implemented across the health system. The strategy highlights that the use of Big Data and Artificial Intelligence remains very limited, and one of its key objectives is to progressively digitalize priority health services according to national standards, ensuring accessibility for patients (p. 10, section 2.1.3 "Services and Applications" [Services et Applications]) ²¹⁹.

Furthermore, the WHO Joint External Evaluation conducted in 2017 confirms that digital health capacities in Madagascar were underdeveloped, particularly in terms of surveillance systems and data management. The report emphasizes the need to establish interoperable, real-time electronic reporting and notification systems, indicating that no comprehensive national digital health infrastructure, including a widespread EHR system, was operational at that time (p. 24, section “Real-time surveillance" [Surveillance en temps réel]) ²²⁰.

More recently, in July 2025, the Malagasy government has introduced a smart queue management system and a digital medical records platform in two university hospitals in Antananarivo as part of a pilot digitalization effort for public hospitals ²²¹.

In May 2025, Madagascar partnered with the HISP Centre at the University of Oslo (HISP UiO), supported by the World Bank, to launch a DHIS2-based One Health platform and interoperable laboratory information system ²²².

2.4.1b Public health system access to individual electronic health records

Score: 0

The national public health system does not currently have full and routine access to individual electronic health records (EHRs) in Madagascar.
While the 2017 Joint External Evaluation (JEE) highlights the need to strengthen digital health infrastructure, improve disease surveillance, and enhance data sharing across sectors, Madagascar still faces significant gaps in the widespread implementation of individual electronic health records (EHRs) (p. 24, Section “Real-time Surveillance” [Surveillance en temps réel]). ²²³

The National Digital Health Strategy 2023–2027 (Stratégie Nationale en Santé Digitale 2023–2027) reveals that only about 2% of healthcare workers involved in digital health had received relevant training by 2023, with digital health capacities such as specialized skills and infrastructure still under development (p. 13, Section 2.2 “Digital Health Maturity” [Maturité de la santé digitale]). ²²⁴

In March 2025, Madagascar launched a government-led hospital digitalization project targeting two major university hospitals as pilot sites: Joseph Ravoahangy Andrianavalona University Hospital Center (CHU HJRA) and Analakely Public Health Care and Service University Hospital Center (CHU SSPA). This initiative aims to improve governance, increase transparency, enhance access to health services, and streamline patient care through the implementation of electronic health records and digital tools. The Ministry of Public Health, in collaboration with the Ministry of Digital Development, recognizes challenges such as limited digital skills, lack of reliable internet access, and resource constraints within health facilities, but aims to expand these efforts nationwide. ²²⁵

The 2017 WHO JEE also observes that although Madagascar has laboratory capacity and some data collection systems, integration and interoperability of these digital systems are insufficient, limiting timely data sharing and decision-making (p. 24, “Real-time Surveillance” [Surveillance en temps réel]). ²²⁶

Madagascar’s Ministry and HISP-UiO announced a DHIS2 platform that will interoperate with the eIDSR and laboratory systems to enhance electronic data sharing across human and animal health agencies. ²²⁷

No substantial evidence was found on comprehensive national-level EHR implementation or digital health governance on the official websites of the Ministry of Public Health. ²²⁸.

2.4.1c Existence of data standards for health record data comparability

Score: 0

Electronic health records are not commonly in use in Madagascar and the country has yet to introduce data standards for its various health information systems (HIS), so there is no evidence of data standards to ensure data is comparable. Niether Madagascar's plan for the HIS' development in 2018-2022 nor the 'Health sector development plan 2015-2019' mentions the existence of, or plans for, electronic health records. The HIS involves the submission of both routine health indicators and disease surveillance information via standardised forms to the regional and then central level. ²²⁹²³⁰ Implementing international (World Health Organisation) standards for HIS and integrating the various health information systems are objectives in the current HIS development plan. ²³¹

The Government of Madagascar and the HISP Centre at the University of Oslo (HISP UiO) have launched a new collaboration to support the digitalization of the country’s One Health platform and laboratory information system, with financial support from World Bank Madagascar. This collaboration will focus on developing a DHIS2-based One Health platform and an interoperable laboratory information system to improve data sharing and strengthen disease surveillance across sectors. ²³²

Madagascar has established Bureau de Normes de Madagascar (BNM), a public interest government body responsible for standardization, product certification, laboratory testing, and legal metrology. ²³³ Madagascar became a member of the International Organization for Standardization (ISO) in 1966, although its current status is that of a Correspondent Member [ISO, 2025]. ²³⁴

There is no evidence of the existence of electronic health records on the website of the Ministry of Public Health , nor on the website of the Pasteur Institute of Madagascar. ²³⁵²³⁶

2.4.2 Data integration between human, animal and environmental health sectors

2.4.2a Data sharing mechanisms

Score: 0

There is no evidence of a mechanism for regular sharing of disease surveillance data between human, animal and environmental health authorities. The 2017 Joint External Evaluation (JEE) report notes that the country lacks standard operating procedures (POS) to ensure effective coordination between the Point Focal National RSI (PFN RSI) and other sectors, and no formalized intersectoral data-sharing platform currently exists (p. 6). Although there are some existing communication channels, information exchange occurs only in the context of significant events rather than on a systematic basis. In particular, regarding zoonoses, while the veterinary services monitor around ten zoonotic diseases and have established good collaboration with human health services for anthropozoonoses, the evaluation highlights the absence of a dense and fully functional network of epidemiological surveillance and sentinel sites across the territory to ensure comprehensive protection against exogenous pathogens (p. 12). ²³⁷

As per the the "Environmental and Social Management Framework" for the Pandemic Preparedness and Strengthening of Basic Services Project (PPSB) implemented by the Ministry of Public Health with funding from the World Bank in 2022, systemic weaknesses within human, animal and environmental health systems that hamper effective disease surveillance" as a primary reason for the project's existence (p. xii). Concerns raised by stakeholders during project consultations reinforce this finding, pointing to a lack of effective data-sharing mechanisms (p. 103). There is a noted "lack of serious coordination" between relevant bodies, the "non-involvement of the veterinary service in vector control," and a general need for "intersectoral collaboration at the strategic and operational level" [p. 104]. A recommendation for the "sharing of epidemiological surveillance data and routine laboratory data" was made (p. 105). ²³⁸

The 2023 AMR Multi-Partner Trust Fund (MPTF) Country Proposal describes the planned development of an integrated national surveillance network and information system for monitoring antimicrobial resistance (AMR) and antimicrobial use (AMU) across human, animal, plant, and environmental sectors. This includes the creation of a national data exchange platform designed to share relevant data in a timely manner between sectors via WHONET, regular reporting to the WHO GLASS network, the WOAH database, FAO INFARM, ATLASS, and TrACSS (p. 21–22). ²³⁹

The 2016 'Masterplan for combatting neglected tropical diseases (NTD) 2016-2020', which plans for surveillance of several diseases including zoonoses, does not mention a mechanism for regular surveillance information sharing. ²⁴⁰ The health ministry's 'Strategic plan for the reinforcement of the Health Information System 2018-2022' does not mention mechanisms for data sharing between human, animal and environmental health authorities. ²⁴¹ A National Operations and Strategy Centre for Epidemiological Surveillance (CNOSSE) was created in late 2016 by the Public Health Ministry, the WHO, the Global Fund and the African Development Bank. There is no evidence that the animal or environmental health authorities participate in CNOSSE. ²⁴²
There is no evidence of a mechanism for regular sharing of disease surveillance data between human, animal and environmental health authorities on the website of the Ministry of Public Health, the Ministry of Agriculture, Animal Husbandry and Fisheries or the Ministry of the Environment and Sustainable Development, nor on the website of the Indian Ocean's Commission One Health network, or on the websites of the Pasteur Institute of Madagascar (PIM). ²⁴³²⁴⁴²⁴⁵²⁴⁶²⁴⁷

2.4.3 Transparency of surveillance data

2.4.3a Availability of de-identified health surveillance data on disease outbreaks

Score: 100

Madagascar makes de-identified health surveillance data on infectious diseases publicly available through various reports on government and institutional websites, though it is not centralized in a single, real-time database.

The Ministry of Public Health (Ministère de la Santé Publique – MSANP) is the primary source for human health data. According to the Health Sector Statistics Yearbook of Madagascar 2022 (Annuaire des Statistiques du Secteur Santé de Madagascar 2022), comprehensive annual data is provided on morbidity and mortality for diseases such as plague, malaria, and tuberculosis (Table 157, p. 182) ²⁴⁸.

The Pasteur Institute of Madagascar (Institut Pasteur de Madagascar – IPM) publishes data in its annual reports. The Activity Report 2023 (Rapport d'activités 2023) details specific surveillance results for diseases where IPM is a reference center, including the confirmation of 96 plague cases, 5 human rabies cases, and the detection of circulating vaccine-derived poliovirus (p. 220, Section 3, Public Health Activities). ²⁴⁹

The Demographic and Health Survey in Madagascar (Enquête Démographique et de Santé à Madagascar – EDSMD-V) 2021 provides key de-identified data points such as the national prevalence of malaria (8%) and anemia (46%) in children, and HIV testing rates among adults ²⁵⁰.

According to the 2017 WHO Joint External Evaluation (JEE) for Madagascar (Évaluation Externe Conjointe OMS 2017 pour Madagascar), there were identified gaps in the national surveillance and reporting systems (p. 25–26, 29). The evaluation noted that while laboratories capable of testing for priority antimicrobial resistance (AMR) pathogens existed, sentinel sites had not been formally designated, and the system did not test for all priority pathogens (p. 16–17). It also highlighted challenges in the interoperability and automation of data sharing between human, animal, and laboratory surveillance systems (p. 29, 35, 37). Hence, data is made publicly available through distinct, periodic reports from various entities rather than a single integrated system ²⁵¹.

2.4.4 Ethical considerations during surveillance

2.4.4a Confidentiality legislation/regulations for identifiable health information

Score: 100

Madagascar has legislation that safeguard the confidentiality of identifiable health information for individuals, including that generated through health surveillance activities. Law No. 2014-038 in Madagascar safeguards the confidentiality of identifiable health information. This law broadly prohibits the processing of "sensitive data," which explicitly includes health information, due to the risks of discrimination and infringement of personal freedoms (Article 18). However, it allows for derogations with appropriate safeguards in specific cases, such as when express consent is given, for vital interests, or for medical diagnosis, care, or public interest health research by health professionals bound by professional secrecy (Article 18). Individuals also have the right to access their health data directly or through a designated doctor (Article 23), and data controllers are obligated to ensure the security of personal data, including against unauthorized access or disclosure (Article 15). Penalties are in place for the unauthorized disclosure of personal data that could undermine an individual's consideration or private life (Article 71). ²⁵²
No other information found on the website of the Ministry of Public Health. ²⁵³

2.4.4b Inclusion of cyber protections in health data confidentiality law/regulation

Score: 100

There is evidence that Madagascar has laws and regulation that protects the confidentiality of identifiable health information for individuals, such as that generated through health surveillance activities, and includes mention of protections from cyber attacks.

Madagascar's Law No. 2014-038 on the Protection of Personal Data, enacted in 2014, establishes comprehensive requirements for the collection, processing, storage, and transfer of personal data, including health information. While the law does not explicitly mention cyberattacks like ransomware, Article 15 imposes a general "Obligation of security" on data controllers to implement all necessary precautions to protect processing and data against "accidental or illicit destruction, accidental loss, alteration, distribution or unauthorized access." Additionally, Article 64 specifies penalties for the "Breach of security" if data controllers fail to implement the prescribed measures in Article 15. ²⁵⁴

Madagascar ratified the African Union Malabo Convention on Cyber Security and Personal Data Protection in 2024. ²⁵⁵ The Convention explicitly mandates the protection of personal data confidentiality and security. Article 20 on confidentiality obligations (p. 23) requires that personal data processing be confidential, carried out only by authorized persons under the controller's instructions. Article 21 on security obligations (p. 23) obliges data controllers to take all appropriate precautions to prevent data from being altered, destroyed, or accessed by unauthorized third parties. Health data, as sensitive personal data, receive special protection under Article 14 (pp. 20-21), which restricts collection and processing of data on the state of health unless specific conditions are met, such as consent or necessity to protect vital interests. The Convention also addresses broader cybersecurity matters relevant to protecting health information from cyber attacks. Article 25 (pp. 25-26) requires State Parties to adopt criminal legislation against cybercrime, including offenses that affect the confidentiality, integrity, and availability of ICT systems and the data they process. This includes protections that encompass attacks like ransomware. Furthermore, Article 29 (pp. 29-31) criminalizes various forms of unauthorized access, data interference, and damage to computer systems and data, establishing a legal deterrent against cyber attacks targeting sensitive information. Articles 24 to 27 (pp. 24-27) require each State Party to develop a national cybersecurity policy and strategy, establish institutional mechanisms and governance structures for cybersecurity, promote a culture of cybersecurity among all stakeholders, and implement measures for coordination, incident response, and public-private partnerships to manage cyber threats and incidents effectively. ²⁵⁶

2.4.5 International data sharing

2.4.5a Cooperative commitments or agreements within regions

Score: 100

Madagascar has made a commitment to share human and animal surveillance data with other countries in the Indian Ocean Commission (IOC) sub-region in general and specifically during a public health emergency for more than one disease. It is one of the member countries of the SEGA One Health Network, which "enables the sharing of epidemiological information provided by the member states' surveillance departments". The SEGA project is currently in its third phase, with a renewed commitment by all member countries in 2019. ²⁵⁷²⁵⁸

The SEGA One Health Network’s official Charter, signed by member states including Madagascar, mandates collaboration and information sharing between human health, animal health, and other sectors across the region as part of a One Health strategy. In 2020, the IOC launched the SEGA One Health Fund to further institutionalize and financially support regional health surveillance and data sharing activities; the European Union contributed €9.35 million for this effort, reinforcing member commitments well after 2019. ²⁵⁹ Madagascar actively participates in sharing influenza surveillance data via the Global Influenza Surveillance and Response System (GISRS) and has continued to contribute viral samples and epidemiological data for international vaccine strain selection through 2025. ²⁶⁰ In March 2018, Madagascar hosted a conference of the African Network of Influenza Surveillance and Epidemiology (ANISE) under the patronage of the health ministry, demonstrating the country's commitment to sharing influenza surveillance data regionally and globally ²⁶¹.

The country's adherence to the International Health Regulations (IHR 2005) serves as a primary legal and operational commitment. As a signatory, Madagascar is obligated to notify the World Health Organization (WHO) of public health events that may constitute a public health emergency of international concern. This legally binding framework necessitates the sharing of surveillance data with the WHO but does not specify provisions to share with other countries. ²⁶²

2.5 Case-based investigation

2.5.1 Case investigation and contact tracing

2.5.1a National support to conduct contact tracing in the event of a public health emergency

Score: 0

There is no evidence that Madagascar’s national plans or strategic frameworks include mechanisms to provide support at the sub-national level to conduct contact tracing in the event of a public health emergency.

There is no pertinent evidence on the websites and Facebook pages of the Ministry of Public Health or the Ministry of Agriculture, Animal Husbandry and Fisheries. ²⁶³²⁶⁴²⁶⁵²⁶⁶

2.5.1b Provision of wraparound services to enable self-isolation/quarantine as recommended

Score: 0

There is no evidence that Madagascar provides wraparound services to enable infected people and their contacts to self isolate or quarantine as recommended, particularly economic support (paycheck, job security) and medical attention.

According to a 2020 World Bank report, during thepandemic, the Malagasy government implemented measures to provide both economic and medical support to individuals affected by quarantine and isolation recommendations. A cash transfer program called "Tosika Fameno" (complementary support) was established to assist vulnerable citizens in cities like Antananarivo, Toamasina, Moramanga, and Fianarantsoa, whose incomes were interrupted by containment measures. This initiative, supported by a $12.7 million contribution from the World Bank's Social Safety Nets II Project, provided unconditional cash transfers of 100,000 ariary (approximately $27) to over 244,000 households to help them meet basic food needs and avoid selling assets. ²⁶⁷

However, a review of the Ministry of Public Health's publications and other government sources did not yield evidence of a permanent, institutionalized "wraparound service" policy that guarantees both economic and medical support for quarantine and isolation for all infectious diseases outside of a declared major health emergency like the COVID-19 pandemic. ²⁶⁸²⁶⁹²⁷⁰²⁷¹

2.5.2 Point of entry management

2.5.2a Strategy for tracing and quarantining international travelers

Score: 0

There is no evidence that Madagascar has a joint plan or cooperative agreement between the public health system and border control authorities to identify suspected and potential cases in international travelers and trace and quarantine their contacts in the event of an active or a future public health emergency.

A WHO country brief on Madagascar states that Madagascar is using its Pandemic Fund allocation to strengthen national emergency preparedness and response systems. A key component of this initiative is to boost human resource capacity by "conducting joint field epidemiology and simulation exercises at points of entry, with tailored modules and cross-border protocols". ²⁷²

However, a review of the Ministry of Public Health's publications and other government sources did not yield evidence of any such arrangements. ²⁷³²⁷⁴²⁷⁵²⁷⁶

2.6 Epidemiology workforce

2.6.1 Existence of applied epidemiology training program such FETP and FETPV

2.6.1a Access to field epidemiology training program in country and/or abroad

Score: 100

Madagascar meets the criterion for applied epidemiology training through both national and regional programs. The Field Epidemiology Training Program (FETP) in Madagascar offers both frontline and master's-level training to human and animal health professionals, combining theory and field practice. A key feature of the FETP in Madagascar is the establishment of a pedagogical committee that provides coordination, strategic direction, and technical oversight for the training program. This committee includes National Focal Points (Technical) for human and animal health, the Centre for Disease Control and Prevention – One Health of the Indian Ocean, and representatives from educational institutions of member states such as the Madagascar Institute of Health (MIH), the National Institute of Public and Community Health (INSPC) of Madagascar, University of Seychelles (UniSeY), and the University of Comoros (UDC). ²⁷⁷ The Field Epidemiology Training Program (FETP) in Madagascar has been running for three years according to the 2017 JEE. This indicates that the FETP started around 2014 (p. 33). ²⁷⁸

2.6.1b Existence of field epidemiology training for animal health professionals

Score: 100

Madagascar’s national Field Epidemiology Training Program (FETP) includes professionals from both the human and animal health sectors.

Madagascar’s FETP is designed as a multi-professional program under the One Health approach, integrating human and animal health agents. It aims to develop capacity in surveillance, investigation, and response to syndromes in human and/or animal diseases at both central and peripheral health system levels. Professionals are eligible for both the Frontline and Master’s FETP tracks. ²⁷⁹

As of October 2024, Madagascar has certified 119 field epidemiologists from these multisectoral cohorts, reflecting ongoing multisectoral workforce development. ²⁸⁰

The 2017 Joint External Evaluation, published in 2018, highlights the existence of a FETP operating for three years, training multisectoral cohorts including animal health professionals, and notes challenges such as certification issues of the program. It also mentions the presence of few veterinary epidemiologists and the need for further strengthening epidemiological training in animal health (pp. 31-33, section Développement du personnel"). ²⁸¹

2.6.2 Epidemiology workforce capacity

2.6.2a Evidence of at least 1 trained field epidemiologist per 200,000 people

Score: 0

There is evidence to suggest that the number of trained epidemiologists in Madagascar is less than 1 per 200,000 people. As of October 2024, Madagascar had 119 certified field epidemiologists trained through the Field Epidemiology Training Program (FETP – Frontline One Health), supported by the SEGA – One Health Network and the National Institute of Public and Community Health (INSPCH). ²⁸² Data regarding the number of trained field epidemiologists prior to the launch of the FETP are not available. The 2017 Joint External Evaluation (JEE) conducted by the WHO similarly highlighted Madagascar’s limited epidemiology workforce capacity and recommended expanding field epidemiology training programs to strengthen rapid response capabilities (p. 31). ²⁸³ Based on World Population Review data indicating Madagascar's 2025 population at 32.7 million ²⁸⁴, the current ratio stands at approximately one field epidemiologist per 274,790 inhabitants. No further relevant evidence was identified on the websites of Ministry of Public Health, Ministry of Environment and Sustainable Development. ²⁸⁵²⁸⁶

Rapid Response

3.1 Emergency preparedness and response planning

3.1.1 National public health emergency preparedness and response plan

3.1.1a National emergency response plan for diseases with pandemic potential

Score: 33.33

Madagascar lacks a comprehensive overarching pandemic preparedness plan, though disease-specific plans exist. The 2015-2016 Contingency Plan addresses key threats including pandemic influenza viruses, malaria, cholera, arboviruses, plague, and MERS-CoV. It encompasses five main areas: planning and coordination, surveillance and evaluation, disease spread reduction, communication, and preservation of essential services. The plan establishes national multi-sector coordination mechanisms through organizational charts and responsibility descriptions, with tables allocating response measures across different entities for various outbreak scenarios (such as national zoonotic outbreaks and external threats) and specific diseases. ²⁸⁷ However, the 2017 WHO Joint External Evaluation found the plan difficult to implement during emergencies due to lacking standard operating procedures (pp. 34-35). ²⁸⁸ In July 2020, the government released a 'Multisectoral Emergency Plan' specifically for the COVID-19 crisis, which does not cover other epidemic or pandemic threats. ²⁸⁹ The World Bank has allocated USD 2.9 million under Subcomponent 1.1 of a funding plan to develop assessments for implementing a One Health approach to pandemic preparedness and infectious disease outbreak response. This funding will support technical assistance, studies, manual development, and multisectoral outreach to create interoperable and interconnected systems. ²⁹⁰ No further evidence identified on the Ministry of Public Health website. ²⁹¹

3.1.1b National public health emergency response plan published in past 3 years

Score: 0

There is no evidence that Madagascar has an overarching plan and hence no evidence that a plan has been updated in the past 3 years. While the country has a disease-specific response plan, the 2020 “Multisectoral Emergency Plan (Plan Multisectoriel D'Urgence – PMDU)”, this document does not cover planning for multiple communicable diseases with pandemic potential. ²⁹² The 'Contingency Plan 2015-2016' identifies key threats including influenza viruses of pandemic potential, malaria, cholera, arboviruses, plague and MERS-CoV, and contains detailed sections on planning for and responding to these disease groups. ²⁹³ The websites of BNGRC (National Office for Risk and Disaster Management), the CPGU (Emergency Prevention and Management Unit under the Prime Minister’s Office) and Ministry of Public Health do not provide any further evidence. ²⁹⁴²⁹⁵²⁹⁶

3.1.1c One health principles by covering multiple threat types

Score: 0

There is no evidence that Madagascar has an overarching plan and hence no evidence that Madagascar follows one health principles within the same.

The “Multisectoral Emergency Plan (Plan Multisectoriel D'Urgence – PMDU)” 2020 employs an intersectoral approach to combat the covid virus, but it does not explicitly state that an overarching national public health emergency response plan follows One Health principles by covering multiple threat types like antimicrobial resistance, zoonotic disease spillover, biological accidents, or deliberate acts. It focuses on the current crisis by integrating health, social, and economic strategies to contain the coronavirus and ensure national resilience and recovery (pp. 4-5). ²⁹⁷

The 'Contingency Plan 2015-2016' partially covers multiple threat types following One Health principles. The plan explicitly identifies major epidemic threats including zoonotic diseases such as plague (bubonic and pulmonary) and Rift Valley Fever, alongside other threats like pandemic influenza, cholera, dengue, chikungunya, and malaria (p. 68). The plan demonstrates One Health coordination for zoonotic disease responses through formal collaboration between the Ministry of Public Health (MSANP) and the Ministry of Livestock (MINELPA). It includes joint surveillance mechanisms, veterinary laboratory capacity at LNDV with support from Institut Pasteur de Madagascar, animal movement restrictions during outbreaks, vaccination of susceptible animals in buffer zones, and coordinated human-animal health investigations (p. 73-76). The plan also establishes protocols for managing animal-to-human disease transmission risks during epizootics (p. 72-73). Antimicrobial resistance is mentioned briefly as a surveillance parameter to monitor "resistance to anti-infectives" during active outbreaks (p. 73), without dedicated preparedness strategies, stewardship programs, or routine AMR monitoring. Biological accidents or deliberate acts are explicitly excluded, the plan states it covers naturally occurring disasters and accidental events (cyclones, floods, epidemics, drought, locust invasion, chemical accidents) but does not address intentional biological threats or laboratory biosafety incidents (p. 1, 11). ²⁹⁸

The websites of BNGRC (National Office for Risk and Disaster Management), the CPGU (Emergency Prevention and Management Unit under the Prime Minister’s Office) and Ministry of Public Health do not provide any further evidence. ²⁹⁹³⁰⁰³⁰¹

3.1.1d Vulnerable populations in national public health emergency response plan

Score: 100

There is no evidence that Madagascar has an overarching plan and hence no evidence that it does it includes consideration of the impact of health equity or mechanisms for identifying and considering the needs of vulnerable populations.

The overall objective of the Malagasy Multisectoral Emergency Plan 2020, specific to the COVID-19 context, is to aid vulnerable populations and respond to the vital challenges of reducing poverty, vulnerability, and precarity (p. 11). Mechanisms include identifying the poorest and most vulnerable based on socio-economic criteria , utilizing 1,428 local Loharano Committees for census, targeting, and aid distribution (p. 14). These programs encompass distributing essential goods through Vatsy Tsinjo to 500,000 vulnerable households , providing conditional Tosika Fameno monetary transfers to an estimated 500,000 informal sector households, and supporting 42,500 unemployed persons with income through HIMO/ACTP cash-for-work projects (pp. 5-6). ³⁰²

The Multi-Hazard Contingency Plan (2015–2016) includes clear provisions addressing health equity and the needs of vulnerable populations. It acknowledges structural vulnerabilities such as widespread poverty, malnutrition, and limited access to essential services, which heighten health risks during emergencies (pp. 12–13). The plan identifies specific groups requiring targeted assistance, including elderly persons, pregnant women, young children, persons with disabilities or chronic illnesses, and unaccompanied children (p. 43). It also highlights increased risks of sexual violence and exploitation, particularly among women, young girls, and children from impoverished families (pp. 43–44). To promote equitable access to services, the plan establishes mechanisms such as the activation of equity funds (fonds d’équité) to provide free healthcare for children under five and pregnant women during emergencies (p. 39), a Protection Cluster responsible for preventing exploitation and supporting vulnerable individuals (pp. 43–44), and formal vulnerability criteria for targeting beneficiaries and prioritizing geographic areas based on need (p. 43; Annex 3a, 3k). While the plan recognizes the ethnic diversity of populations in highly vulnerable regions such as the Grand Sud, including the Antanosy, Antandroy, Mahafaly, Vezo, and Bara groups (p. 9), it does not include specific strategies to address ethnic or linguistic barriers in response implementation. ³⁰³

3.1.2 Private sector involvement in response planning

3.1.2a Mechanism to engage private sector in outbreak preparedness/response

Score: 100

A specific national mechanism for engaging with the private sector across all outbreak emergencies for preparedness and response is not explicitly described as fully implemented in Madagascar. There is evidence of private sector involvement in response activities and emerging dialogue platforms, but not of a formalized mechanism integrated into the national health security framework.

While initiatives such as the "Private Sector Humanitarian Platform Madagascar" ³⁰⁷ exist, it is not clear if the Platform is currently actively cooperating with the government of Madagascar and if there is a mechanism for cooperation. The 2020 “Multisectoral Emergency Plan (Plan Multisectoriel D'Urgence – PMDU)” only focuses on COVID-19 and does not include an overarching strategy, nor does it mention private sector involvement in assisting with outbreak emergency preparedness and response. ³⁰⁸ The previous available version of the country's contingency plan is the' Contingency Plan 2015-2016'. At the strategic level, a Pandemic and Major Epidemic Steering Committee (CPLPEM) was created, with representatives from the ministries of health and the interior, from key health sector NGOs, and from "essential private sectors". These private sectors include finance, defence, energy, food, transport, telecommunication, water, livestock, commerce and communication (p. 70). ³⁰⁹ There is no evidence that the CPLPEM, the Private Sector Humanitarian Platform Madagascar, or other private sector initiatives currently play a role in outbreak emergency preparedness and response, or that a mechanism for cooperation with the private sector exists, as these are not mentioned on the website of the National Office for the Management of Risks and Catastrophes (BNGRC), the Public Health Ministry, or the Office of the Prime Minister or the Private Sector Humanitarian Platform Madagascar. ³¹⁰³¹¹³¹²³¹³. The CPLPEM does not have a website.

According to the Joint External Evaluation of IHR Core Capacities of the Republic of Madagascar 2017, Madagascar's preparedness structures rely on multisectoral coordination including the Standing Inter-Agency Committee (Comité Permanent Inter-Agences) and involve the private sector primarily through essential services frameworks (p. 1, 34-35). ³¹⁴ The 2024 IOM Crisis Response Plan, which includes a strategy to strengthen engagement with "private sector platforms" to mobilize resources for emergency preparedness and response (p. 10). ³¹⁵

3.1.3 Non-pharmaceutical interventions planning

3.1.3a Policy/plan/guidelines in place to implement non-pharmaceutical interventions (NPIs)

Score: 50

Madagascar has demonstrated both framework-level planning and practical implementation of non-pharmaceutical interventions (NPIs) across multiple diseases. The 2020 “Multisectoral Emergency Plan (Plan Multisectoriel D'Urgence – PMDU)” focuses on COVID-19 only and describes planned non-pharmaceutical interventions (NPIs). ³¹⁶ The Multi-Risk National Contingency Plan, Republic of Madagascar (Plan National de Contingence Multi-Risques, République de Madagascar) (2015–2016) includes a dedicated section on "Major Epidemics and Pandemics" (Épidémies majeures et pandémies) (Section IV.3). Within this section, the plan sets out rapid reaction matrices and operational objectives, including "Reduction of disease spread" (Réduction de la diffusion de la maladie) (Section IV.3.4.2). These provisions correspond to standard NPIs such as measures to limit human-to-human transmission, communication strategies, and the preservation of essential services (pp. 31, 48). However, the contingency plan covered only the period 2015–2016 and has not been publicly updated since. ³¹⁷ The Joint External Evaluation of Core IHR Capacities of the Republic of Madagascar 2017 confirms the existence of a "National Pandemic and Major Epidemic Preparedness and Response Plan" (Plan national de préparation et de riposte aux pandémies et aux épidémies majeures) and related standard operating procedures. The JEE notes that these plans and procedures were in place but required updating and operationalization to be fully effective, particularly in terms of coordination and implementation (pp. 35–36, Section R.1.1; pp. 58–61, Document inventory). ³¹⁸

Event-specific reporting by the World Health Organization, "Plague – Madagascar" (Disease Outbreak News, 1 October 2021), also documents the use of NPIs in plague outbreaks. These included isolation of cases, chemoprophylaxis of contacts, disinfection of households, vector and rodent control, and active case finding, showing the routine application of NPI measures during epidemic response (Sections "Public health response" and "WHO advice"). ³¹⁹

The World Bank press release "Madagascar: $134.9 Million to Improve Pandemic Preparedness and Basic Health Services Delivery" (30 March 2022) highlights external financing to strengthen Madagascar's preparedness, including implementation of the National Action Plan for Health Security and reinforcement of surveillance systems. While it supports the institutional framework required to implement NPIs, the press release itself does not detail specific NPI guidelines (para. 2-3). ³²⁰ No other relevant evidence of a consolidated national NPI policy or guideline was found in the official publications of the Ministry of Public Health. ³²¹

3.2 Exercising response plans

3.2.1 Activating response plans

3.2.1a Completion of biological-focused IHR exercise with the WHO in past year

Score: 100

Madagascar has not activated its national emergency response plan for an infectious disease outbreak within the past year, but it has completed a national-level simulation exercise that tested biological and disaster response systems under the coordination of the United Nations Office for Disaster Risk Reduction (UNDRR) and the National Office for Risk and Disaster Management (BNGRC). Recent Conseil des Ministres reports from the Presidency of Madagascar (Présidence de la République de Madagascar) confirm that the nation formally declared the end of its type 1 vaccine-derived poliovirus (cVDPV1) epidemic in May 2025 and implemented strict sanitary control measures at ports and airports to prevent reinfection. These measures were taken under the Ministry of Public Health (Ministère de la Santé Publique) but did not amount to activating the national emergency response plan under exceptional legal or emergency provisions. ³²² Previous ministerial communications from early 2024 noted preventive health surveillance measures for cholera and community-level control mechanisms at borders, but again, no decree or statement indicates a formal activation of the national emergency or public health response system. ³²³

The UNDRR article “Indian Ocean countries put their preparedness to the test” documents a series of simulation exercises, including in Madagascar, that aimed to test national early warning and early action systems. It notes that from August to October 2024, table-top and functional drills were held in Madagascar, Mauritius, and Seychelles to strengthen national coordination and preparedness for multi-hazard scenarios, forming part of the Indian Ocean regional roadmap for disaster readiness. ³²⁴ The UNDRR “Second Advisory Panel Annual Summary Report” (2024) also references simulation exercises conducted by national authorities in Madagascar, highlighting their role in testing early warning and multi-sectoral response capacities as part of the 2024–2025 regional resilience program (p. 14). ³²⁵

3.2.1b Evidence of bio-focused exercise to identify gaps/best practices

Score: 0

There is no explicit evidence that states that Madagascar conducted an official after-action review (AAR) or biological threat exercise evaluation that identifies a formal list of gaps and best practices with a subsequent developed national plan specifically targeting infectious disease or biological threat response improvements in the past year. A 2025 national disaster preparedness baseline assessment highlights ongoing structural weaknesses in Madagascar’s Disaster Risk Management (DRM) system, calling for strengthened communication, coordination, infrastructure, and data systems. This reflects current recognition of gaps but is more generalized and not tied to a specific infectious disease or biological-threat response after action review. ³²⁶ The websites of BNGRC (National Office for Risk and Disaster Management), the CPGU (Emergency Prevention and Management Unit under the Prime Minister’s Office) and Ministry of Public Health do not provide any further evidence. ³²⁷³²⁸³²⁹

3.2.2 Private sector engagement in exercises

3.2.2a Evidence of national-level biological threat-focused exercise that includes private sector

Score: 0

There is insufficient evidence to confirm that, within the past year, Madagascar has undergone a national-level biological threat-focused exercise that has included private sector representatives.

Madagascar has recognized the value of simulation exercises and drills in strengthening preparedness capacity. The World Bank’s Pandemic Preparedness and Basic Health Services Delivery Project (2022) identifies simulation exercises as a performance indicator, aiming for at least 50 percent of health districts to conduct such activities by the end of the project period. ³³⁰ The country has also engaged private-sector partners in humanitarian and disaster response platforms, such as the Plateforme Humanitaire du Secteur Privé (PSHP), which indicates an enabling framework for cross-sectoral engagement. ³³¹

3.3 Emergency response operation

3.3.1 Emergency response operation

3.3.1a Existence of Emergency Operations Center (EOC)

Score: 100

Madagascar has an emergency operations centre (EOC) for health-related emergencies. In 2016, the National Operational and Strategic Centre for Epidemiological Surveillance (CNOSSE) was launched by the Directorate of Health Monitoring and Epidemiological Surveillance (DVSSE), under the health ministry. It provides leadership, information, technical expertise and basic services regarding emergency response to health threats. As control centre for the country's electronic disease surveillance, it will organize rapid and coordinated interventions. During the 2017 plague outbreak, it held daily meetings of the crisis staff to manage the response.³³⁵ Madagascar also has an EOC for natural disasters, CERVO, which is under the National Office of Risk and Disaster Management (BNGRC).³³⁶³³⁷. According to the 2017 WHO Joint External Evaluation for Madagascar, both CNOSSE and CERVO have been activated several times and have demonstrated their reliability. They have adequate equipment and provide 24-hour coverage (p. 36).³³⁸ Madagascar also has an Office for the prevention and management of emergencies (CPGU), which reports to the Prime Minister. ³³⁹

3.3.1b Requirement for EOC to conduct/evidence EOC conducts at least annual drills

Score: 0

There is no evidence that either Madagascar's public health emergency operations centre (PHEOC) or its general emergency operations centre (EOC) is required to conduct a drill at least once a year. The World Bank’s Pandemic Preparedness and Basic Health Services Delivery Project (2022) introduces simulation exercises as a performance indicator, with a target that at least 50 percent of health districts will have conducted a simulation within the past 24 months by the end of the project period (pg. 50). ³⁴⁰ However, there is no evidence of a legal requirement.

The PHEOC is the National Operational and Strategic Centre for Epidemiological Surveillance (CNOSSE) and the general EOC is the Centre for Study and Reflection of Surveillance and Direction (CERVO) (p. 36).³⁴¹ There is no evidence that CNOSSE or CERVO have a requirement for drills, or have conducted a drill, from the 2017 WHO Joint External Evaluation for Madagascar ³⁴², on the websites of the Public Health Ministry ³⁴³, the World Health Organisation (WHO) in Madagascar ³⁴⁴, the official Facebook page of the World Health Organisation (WHO) in Madagascar ³⁴⁵, the 2017 Annual Report of the World Health Organisation (WHO) in Madagascar ³⁴⁶, or on the website of the Bureau of Risk and Disaster Management (BNGRC) ³⁴⁷. The overarching contingency plan for disease outbreak emergencies pre-dates CNOSSE's creation and does not mention a requirement for drills for CERVO.³⁴⁸

3.3.1c EOC activation within 120 minutes of identification of emergency/scenario

Score: 0

There is no public evidence that Madagascar’s Emergency Operations Center (EOC) has, within the last year, conducted a coordinated emergency response or exercise that was activated within 120 minutes of identifying a public health emergency.

An April 2025 press release from the Indian Ocean Commision (Commission de l’océan Indien) confirms that Madagascar has decentralized its COUSP system, trained over 130 professionals, and integrated the Incident Management System (IMS) to strengthen rapid activation capacity at national and regional levels (p. 1) However, the communication does not provide verifiable evidence of a drill or emergency response exercise being activated within 120 minutes of detection. ³⁴⁹

No further relevant evidence was identified in the publications of the Ministry of Public Health (Ministère de la Santé Publique). ³⁵⁰

3.4 Linking public health and security authorities

3.4.1 Public health and security authorities linked for a biological event

3.4.1a Joint exercise/procedures for potential deliberate biological events

Score: 0

There is no publicly available evidence indicating that Madagascar has conducted an exercise involving public health, animal health, the private sector, and national security authorities to respond to a potential deliberate biological event or bioterrorism attack, nor are there publicly available intersectoral standard operating procedures, guidelines, or memorandums of understanding specifically addressing such scenarios.
The Joint External Evaluation of IHR Core Capacities of the Republic of Madagascar explicitly reported that Madagascar did not have intersectoral SOPs, protocols, or agreements in place for deliberate biological events. The evaluation highlighted the absence of a national biosafety and biosecurity strategy, limited intersectoral coordination, and no systematic capacity to manage deliberate biological threats, assigning low scores (1–2) to the relevant indicators (pp. 45–47) ³⁵¹.

Legislatively, Madagascar has criminalized bioweapons under Law No. 2014-005 against Terrorism and Transnational Organized Crime, which prohibits the use, delivery, or transport of biological weapons with penalties up to life imprisonment (Articles 8–9, 11–16, 33) ³⁵². Domestic health legislation, such as the Code de la Santé (Loi n°2011-002, Government of Madagascar, 2011), establishes a framework for public health emergencies and general sanitary control but does not contain provisions tailored to deliberate biological events or bioterrorism response ³⁵³.

3.5 Risk communication

3.5.1 Risk communication planning

3.5.1a Risk communication plan for specific use during a public health emergency

Score: 0

Madagascar does not have in place in the national public health emergency response plan a section detailing a risk communication plan that is specifically intended for use during a public health emergency.

The Joint External Evaluation of IHR Core Capacities of the Republic of Madagascar (Mission Report, 10–14 July 2017, published January 2018) includes a section on “Communication des risques” (pp. 48–50). It describes the use of the “URGENCE” network for information dissemination during Cyclone Enawo and mentions activities carried out for communication with communities. The report highlights the absence of a formal national strategy and explicitly recommends the development of a national multi-hazard and multisectoral risk communication plan that specifies roles, procedures, priority tasks, and responsibilities (pp. 49–50). ³⁵⁴

The Pandemic Preparedness and Basic Health Services Delivery Project (World Bank, 2022) states in Annex 2 that the project will support the Ministry of Public Health in the development of a multi-sectoral strategy for communication of health risks. This activity is included in the results framework as a required deliverable (Annex 2, p. 27). ³⁵⁵

The Stratégie Nationale de Santé Digitale de Madagascar 2023–2027 (Ministère de la Santé Publique, 2023) does not outline a detailed operational risk communication plan for public health emergencies. ³⁵⁶

No other relevant evidence was found on the official website of the Ministry of Public Health in its publications section. ³⁵⁷

3.5.1b Inclusion of different population & sector needs in risk communication plan

Score: 0

The Joint External Evaluation of IHR Core Capacities of the Republic of Madagascar contains a subsection on “Risk Communication (Communication des risques)” (pp. 48-50). It notes that communication activities have been carried out in emergencies such as Cyclone Enawo and through the “URGENCE” network but emphasizes that there is no formalized national risk communication strategy. The JEE team specifically recommended that Madagascar develop a national, multi-hazard, multisectoral risk communication plan that would clearly assign roles, procedures, tasks, and responsibilities (pp. 49-50) ³⁵⁸.

The Madagascar Pandemic Preparedness and Basic Health Services Delivery Project (World Bank, 2022) identifies the development of a multisectoral health risk communication strategy as a planned activity. Annex 2 of the document states that this support is part of the project’s objectives and is listed in the results framework as a deliverable (Annex 2, p. 27) ³⁵⁹.

The National Digital Health Strategy of Madagascar 2023–2027 (Stratégie Nationale de Santé Digitale de Madagascar 2023-2027) (Ministère de la Santé Publique, 2023) includes references to “Risk Communication (Communication des risques)” does not provide a detailed operational plan specific to emergencies ³⁶⁰.

A review of the publications section of the Ministry of Public Health did not identify any additional national legislation, regulations, or strategies containing a risk communication plan for public health emergencies ³⁶¹.

3.5.1c Designation of a specific government spokesperson during a public health emergency

Score: 0

No other relevant evidence was found on the official website of the Ministry of Public Health in its publications section. ³⁶⁵

3.5.2 Public health systems communication

3.5.2a Government use of media platforms to share info on public health emergencies

Score: 0

There is no publicly available evidence indicating that the public health system has actively shared messages via online media platforms (e.g., social media, website) to inform the public about ongoing public health concerns and/or dispel rumors, misinformation, or disinformation.

The Ministry of Public Health’s (Ministère de la Santé Publique – MSANP) Twitter account, i.e., "Ministeran'ny Fahasalamam-bahoaka" (@Msanp_Mada), shows no posts since joining the platform in 2021 ³⁶⁶, and their Facebook page (Page Facebook : Ministère de la Santé Publique de Madagascar) also contains no posts despite being created in 2010 ³⁶⁷.

Similarly, the Republic of Madagascar’s official Twitter account (Compte Twitter Officiel de la République de Madagascar – @MadagascarGov) has remained inactive since joining in 2021 ³⁶⁸, and the Presidency’s Twitter account (Compte Twitter de la Présidence – @PresidenceMada) shows no activity despite being established in 2014 ³⁶⁹.

While the Presidency’s Facebook page (Page Facebook : Présidence de la République de Madagascar) has been active since 2014, posts primarily focus on facility inaugurations and development projects, with no health-related communications found in the past year ³⁷⁰.

3.5.2b Evidence that senior leaders have shared mis/disinformation on infectious diseases

Score: 0

There is evidence that the President of Madagascar has disseminated misinformation regarding infectious diseases, although not in the past two years. In April 2020, President Andry Rajoelina introduced "Covid-Organics," a herbal tonic derived from Artemisia annua, claiming it could prevent and cure COVID-19. ³⁷¹³⁷² This announcement was made despite the absence of clinical trials or scientific evidence supporting the efficacy of the tonic. In May 2021, as the South African variant of COVID-19 reached Madagascar, President Rajoelina asserted that no vaccine was effective against it. ³⁷³ Journalist Arphine Helisoa was arrested in April 2020 for allegedly spreading "fake news" after questioning the government's handling of the pandemic and the promotion of Covid-Organics. ³⁷⁴ No further relevant evidence was identified on the website of the Ministry of Public Health (Ministère de la Santé Publique) ³⁷⁵.

3.6 Access to communications infrastructure

3.6.1 Internet users

3.6.1a Percentage of households with Internet

Score: 24.37

3.6.2 Mobile subscribers

3.6.2a Mobile-cellular telephone subscriptions per 100 inhabitants

Score: 40.81

3.6.3 Female access to a mobile phone

3.6.3a Gender gap in access to a mobile phone (percentage points)

Score: 70

3.6.4 Female access to the Internet

3.6.4a Gender gap in access to the Internet (percentage points)

Score: 79.17

3.7 Trade and travel restrictions

3.7.1 Trade restrictions

3.7.1a Restrictions on export/import of medical goods due to an infectious disease outbreak

Score: 100

There is no publicly available evidence indicating that Madagascar has implemented restrictions on the export or import of medical goods such as medicines, oxygen, medical supplies, or PPE, due to an infectious disease outbreak in the past year.

Reviews of public health announcements and national news outlets within the last year do not show a change in this stance or the implementation of new trade restrictions on medical goods. Routine import controls and safety requirements continue to apply, but no new interventions based on an outbreak or international recommendations have been introduced.

3.7.1b Restrictions on movement and/or exports/imports due to disease outbreak

Score: 100

There is no publicly available evidence indicating that Madagascar has implemented restrictions on the export or import of non-medical goods (e.g., food, textiles) due to an infectious disease outbreak.

Subsequent checks of public announcements, government sources, and national news within the last year do not show any indication of such restrictions being implemented. ³⁷⁶³⁷⁷³⁷⁸³⁷⁹³⁸⁰

3.7.2 Travel restrictions

3.7.2a Evidence of travel ban due to an infectious disease outbreak

Score: 0

Madagascar has not implemented formal inbound or outbound travel restrictions due to an infectious disease outbreak in the past year.

According to the World Health Organization’s Statement of the Forty-second Meeting of the Polio IHR Emergency Committee (28 July 2025), international travelers from countries with poliovirus transmission, including Madagascar, are advised to receive a dose of polio vaccine (bOPV or IPV) between four weeks and 12 months prior to international travel, or at least by the time of departure for urgent travel. This recommendation applies to travelers from all points of departure and is based on scientific evidence and the International Health Regulations framework. ³⁸¹

Subsequent checks of public announcements, government sources, and national news within the last year do not show any indication of such restrictions being implemented. ³⁸²³⁸³³⁸⁴³⁸⁵

3.7.2b Risk-based approach to international travel-related measures

Score: 0

Madagascar does not apply a comprehensive risk-based approach to international travel-related health measures. The 2017 WHO Joint External Evaluation of Core Capacities of the International Health Regulations (2005) of the Republic of Madagascar (Évaluation Externe Conjointe des capacités de base du Règlement Sanitaire International (2005) de la République de Madagascar) confirms that Madagascar has foundational capacities for applying risk-based health measures at designated points of entry. Under indicator P.3 Points of Entry (Points d'entrée), the evaluation notes effective routine public health measures, including vector control and conveyance inspection capabilities (p. 40). ³⁸⁶

No other relevant information was found on Ministry of Public Health of Madagascar and the Institut Pasteur of Madagascar. ³⁸⁷³⁸⁸³⁸⁹

Health System

4.1 Health capacity in clinics, hospitals and community care centers

4.1.1 Available human resources for the broader healthcare system

4.1.1a Doctors per 100,000 people

Score: 2.04

4.1.1b Nurses and midwives per 100,000 people

Score: 2.51

4.1.1c Updated health workforce strategy to address human resource shortfalls

Score: 0

There is insufficient evidence that Madagascar has a dedicated national health workforce strategy updated in the past five years. The country’s most recent overarching framework is the Health Sector Development Plan 2020–2024, which outlines broad priorities for strengthening the health system, including references to human resources (p. 69). ³⁹⁰ The 2017 WHO JEE notes the existence of a National Human Resources for Health Development Plan with strategies for training, recruitment, and retention, but it remains far from its objectives, with a shortage of around 7,500 health workers and weak rural retention measures (pp. 50–51). ³⁹¹ This policy document is not available online.

The World Bank’s Investing in Human Capital Development Policy Financing Program (2020) emphasize improving HR competencies, regulating and accrediting health training institutions, and mandating the use of AUGURE, a centralized digital human resources management system designed to track personnel data and improve the equitable distribution of health workers nationwide (pp. 27–28, 75). ³⁹² However, no standalone HRH strategy was identified in publicly available sources from the Ministry of Public Health, the Ministry of Education, or other platforms. ³⁹³³⁹⁴

4.1.1d Health system capacity for essential health services

Score: 0

Madagascar’s health system faces significant challenges and currently lacks sufficient capacity to consistently deliver essential health services.

According to the World Bank’s 2022 Pandemic Preparedness and Basic Health Services Delivery Project report, Madagascar has persistent geographic disparities in access to healthcare, with approximately 35% of the population living more than 10 kilometers from a health facility, particularly affecting rural communities. The report details how these disparities lead to delayed care and challenges in equitable service delivery (pp. 8, 14). This project further highlights the overall health system’s “basic level” functioning, constrained by shortages in resources, qualified personnel, and infrastructure necessary for effective pandemic preparedness and routine health service delivery (pp. 8, Results section). ³⁹⁵

The Madagascar ACCESS Activity Midterm Evaluation Report (2023) details some improvements in provider capacity and service quality but highlights ongoing supply chain challenges. Persistent stockouts and shortages of essential medicines and health commodities undermine service continuity, while weaknesses in logistics management and information systems limit sustained progress (pp. 11, 22). ³⁹⁶

The 2017 Joint External Evaluation (JEE) report for Madagascar, accessible via the WHO’s official JEE portal, documents critical gaps in surveillance, laboratory capacity, emergency response, and risk communication. These weaknesses compromise both health emergency preparedness and the consistent delivery of essential health services. The report underscores the necessity of strengthening multi-sectoral coordination, boosting health workforce capacity, and improving operational logistics to address systemic deficiencies (WHO Joint External Evaluation Report, Madagascar, 2017, pp. 15-30). Government plans and policies referenced in the JEE reinforce these priorities. ³⁹⁷

No recent or pertinent information was found on the official websites of Madagascar’s Ministry of Public Health or Pasteur Institue of Madagascar. ³⁹⁸³⁹⁹

4.1.1e Essential health services continuity plan for public health emergencies

Score: 0

While Madagascar has policies and projects for responding to public health emergencies, there is limited explicit evidence of a comprehensive, institutionalized plan that guarantees the continuity of essential routine health services during such events.

The Health Sector Development Plan 2020–2024 (PDSS) identifies emergency preparedness and response as a priority area and emphasizes strengthening primary health care and health system resilience, which could support continuity measures (Objective 5, pp. 80–83). ⁴⁰⁰ The Pandemic Preparedness and Basic Health Services Delivery Project (World Bank, 2022) goes further by including a dedicated component on “Strengthening the Resilience and Performance of Basic Health Services” and financing measures such as mobile and outreach services, procurement of essential commodities, and safeguarding reproductive, maternal, child, and adolescent health during crises (Component 2, pp. 33–36). ⁴⁰¹

The Joint External Evaluation (JEE) of IHR Core Capacities for Madagascar (2017) found gaps in coordination and communication frameworks and did not document nationwide, facility-level continuity plans for essential health services during emergencies (pp. 12–14, 94–96). ⁴⁰² Furthermore, the websites of BNGRC (National Office for Risk and Disaster Management), the CPGU (Emergency Prevention and Management Unit under the Prime Minister’s Office) and Ministry of Public Health do not provide detailed evidence of health-sector continuity arrangements. ⁴⁰³⁴⁰⁴⁴⁰⁵

4.1.2 Facilities capacity

4.1.2a Hospital beds per 100,000 people

Score: 3.59

4.1.2b In-country capacity to isolate patients with highly communicable diseases

Score: 0

There is insufficient evidence to confirm that Madagascar currently has facilities capable of isolating and treating patients with highly communicable diseases.

The 2024 Madagascar Crisis Response Plan mentions supporting national contingency planning in and capacity building but without specification of functional biocontainment patient care units or isolation rooms ⁴⁰⁶. The National Contingency Plan for Pandemic and Epidemic Preparedness (2015–2016) identified the need to establish 11 isolation rooms or centers but did not specify which health facilities would host them. ⁴⁰⁷ During the 2017 plague outbreak, updates from the Bureau of Risk and Disaster Management (BNGRC) indicated that this need was still largely unmet, highlighting an urgent requirement for materials to equip isolation centers.⁴⁰⁸ A report by the European Centre for Disease Prevention and Control noted that five isolation and treatment centers had been temporarily set up in the capital, Antananarivo, during the outbreak. ⁴⁰⁹ An after-action review of the 2017 response did not reference specific facilities but cited the use of plague triage and treatment centers as an example of good practice.⁴¹⁰ There is no publicly available evidence from the Ministry of Health or the 2017 WHO Joint External Evaluation that permanent isolation facilities exist or what their capacity might be. ⁴¹¹⁴¹² While the Pasteur Institute of Madagascar operates a rabies treatment center, there is no evidence it provides patient isolation capabilities. ⁴¹³

4.1.2c Demonstrated capacity / evidence of plan to expand isolation capacity

Score: 0

Explicit evidence demonstrating that Madagascar has developed, updated, or tested a specific plan for expanding isolation capacity in response to an infectious disease outbreak within the past two years is not publicly available. The 2024 Madagascar Crisis Response Plan talks about coordination with the National Bureau for Disaster Risk Management (BNGRC) is emphasized for disaster response but references do not include formal outbreak isolation capacity plans or their testing (p. 6). ⁴¹⁴ The National Contingency Plan for preparing for and responding to major pandemics and epidemics, valid for 2015-16, stated the need to develop and equip 11 isolation rooms/centres. It did not identify which health facilities would house them (p. 39).⁴¹⁵

The Pasteur Institute of Madagascar houses a rabies treatment centre, but there is no evidence on IPM’s website that it has patient isolation facilities.⁴¹⁶ No relevant information was found on the websites of Ministry of Public Health or University Hospital Centres (CHU) . ⁴¹⁷⁴¹⁸

4.2 Supply chain for health system and healthcare workers

4.2.1 Routine health care and laboratory system supply

4.2.1a National procurement protocol for the acquisition of routine laboratory/medical supplies

Score: 0

There is no clear evidence of a fully established and functional national and/or international procurement protocol specifically utilized by the Ministries of Health and Agriculture in Madagascar for the routine acquisition of laboratory and medical supplies.

The 2017 Joint External Evaluation (JEE) reported that Madagascar does not have an efficient multisectoral system for the acquisition and distribution of consumables, reagents, and other supplies for laboratories, and that no sustainable mechanism exists to ensure regular procurement and supply. Acquisitions were noted to occur largely on an ad hoc and donor-driven basis. The JEE recommended the development or strengthening of a national strategy to guarantee transparent and sustainable provision of laboratory materials (JEE, Section D.1.4, pp. 31–32) ⁴¹⁹. Although the country has a general Public Procurement Code (Law No. 2016-055) applicable to all ministries, this framework serves as a broad legal basis for tenders and contracts rather than a specialized health-sector procurement protocol ⁴²⁰.
No other relevant evidence was identified on the websites of Ministry of public Health or Ministry of Agriculture and livestock. ⁴²¹⁴²²

4.2.2 Stockpiling for emergencies

4.2.2a Stockpile of medical supplies for national use during a public health emergency

Score: 0

Madagascar lacks a comprehensive overarching pandemic preparedness plan, though disease-specific plans exist. The 2015-2016 Contingency Plan addresses key threats including pandemic influenza viruses, malaria, cholera, arboviruses, plague, and MERS-CoV. It encompasses five main areas: planning and coordination, surveillance and evaluation, disease spread reduction, communication, and preservation of essential services. The plan establishes national multi-sector coordination mechanisms through organizational charts and responsibility descriptions, with tables allocating response measures across different entities for various outbreak scenarios (such as national zoonotic outbreaks and external threats) and specific diseases. ⁴²³ However, the 2017 WHO Joint External Evaluation found the plan difficult to implement during emergencies due to lacking standard operating procedures (pp. 34-35). ⁴²⁴ In July 2020, the government released a 'Multisectoral Emergency Plan' specifically for the COVID-19 crisis, which does not cover other epidemic or pandemic threats. ⁴²⁵ The World Bank has allocated USD 2.9 million under Subcomponent 1.1 of a funding plan to develop assessments for implementing a One Health approach to pandemic preparedness and infectious disease outbreak response. This funding will support technical assistance, studies, manual development, and multisectoral outreach to create interoperable and interconnected systems. ⁴²⁶ No further evidence identified on the Ministry of Public Health website. ⁴²⁷

4.2.2b Stockpile of laboratory supplies for national use during a public health emergency

Score: 0

Madagascar has stocks of medical supplies for use in a public health emergency, but there is no evidence that Madagascar has stocks of laboratory supplies. As per Madagascar's Joint External Evaluation from 2017, the government has set up an Infrastructure, Logistics and Legacy Service (SILOP) responsible for receiving and storing medical equipment, and a Response Service for Emergencies, Epidemics and Disasters (SURECA), but it is not clear if they have stocks of laboratory supplies (p. 40). According to the World Health Organization’s 2017 Joint External Evaluation, SALAMA is responsible for supply of laboratories with reagents through a central purchasing unit for essential medicines (p. 23). ⁴²⁸ There is a section on stockpiling on its website, but no details of accessing/providing laboratory supplies in an emergency situation are available. ⁴²⁹ There is no evidence of the existence of stocks of laboratory supplies on the websites of the Ministries of Public Health, the Bureau of Risk and Disaster Management (BNGRC), the Office for the prevention and management of emergencies (CPGU). There is no evidence on the website of the Madagascar Drug Agency. ⁴³⁰⁴³¹⁴³²⁴³³

4.2.2c Annual review of national stockpile to ensure sufficient supply

Score: 0

There is no evidence that Madagascar conducts or requires an annual review of the national stockpile to ensure the supply is sufficient for a public health emergency. According to the World Health Organization’s 2017 Joint External Evaluation, SALAMA is is the central procurement agency for essential drugs and medical supplies (p. 23). Laboratories in Madagascar face problems supplying reagents and consumables, but there is no mention of an annual review of the national stockpile (p. 21). ⁴³⁴ The central procurement agency for essential drugs and medical supplies (SALAMA) does not provide evidence of such an annual review on its official website. ⁴³⁵⁴³⁶ The 'Response Service for Emergencies, Epidemics and Disasters (SURECA)' under the Ministry of Public Health does not have an official website, and no information was found through online searches regarding its mandate to conduct annual stockpile reviews. Additionally, no information was found on the websites of the Ministry of Public Health ⁴³⁷. Although Madagascar has conducted After Action Reviews (AARs), such as following the 2017–2018 plague outbreak, to improve epidemic preparedness, there is no indication that these processes include a formal, annual stockpile review. ⁴³⁸

4.2.3 Manufacturing and procurement for emergencies

4.2.3a Plan/agreement to produce/procure medical supplies during a public health emergency

Score: 0

Specific plans or mechanisms covering the full scope of these criteria regarding medical supplies during a public health emergency in Madagascar are not explicitly detailed as fully established or tested. The 2017 Joint External Evaluation (JEE) of Madagascar does not contain evidence of a plan or agreement to utilize public and/or private sector domestic (including regional) manufacturing to produce medical supplies during emergencies, with the country scoring 1 (no capacity) for both indicators related to systems for sending and receiving medical means and health personnel during public health emergencies (pp. 40-41). ⁴³⁹ The 2022 World Bank Pandemic Preparedness and Basic Health Services Delivery Project describes investments to strengthen emergency response capacity at the local level, including prepositioning of equipment, materials, reagents and supplies necessary to ensure the management of health emergencies at the regional level to support districts, and supports procurement of essential commodities managed through the existing supply chain management system (pp. 22-23, 25). ⁴⁴⁰ However, these documents do not specify expedited procurement procedures specifically designed for emergency activation. Concerning the expediting of medical supplies through points of entry during a public health emergency, the JEE report indicates that Madagascar scored 1 (no capacity) for both routine capacities and effective public health action at points of entry (pp. 46-48). ⁴⁴¹ The 2022 project proposes to strengthen capacity to detect and manage public health events at the nine main Ports of Entry through standardizing technical platforms and infrastructure, but no explicit mechanism designed to expedite medical supplies through points of entry during emergencies is documented as currently operational (pp. 26-27). ⁴⁴²
No additional information was found on the website of Ministry of Public Health. ⁴⁴³

4.2.3b Plan/agreement to produce/procure lab supplies during a public health emergency

Score: 0

There is no evidence that Madagascar’s national plans or strategic frameworks include mechanisms meet any of these criteria.

There is no pertinent evidence on the websites and Facebook pages of the Ministry of Public Health or the Ministry of Agriculture, Animal Husbandry and Fisheries. ⁴⁴⁴⁴⁴⁵⁴⁴⁶⁴⁴⁷

4.2.3c Mechanism emergency logistics and supply chain management

Score: 100

While Madagascar has established mechanisms for logistics and supply chain management in health emergencies through its 2015–2016 National Contingency Plan, there is no clear evidence of a fully comprehensive, operational system that meets all criteria. The plan defined central and subnational logistics structures, prepositioning of supplies, and vaccine-related logistics, but it has not been updated since 2016 (pp. 14–17). ⁴⁴⁸ The 2017 Joint External Evaluation (JEE) noted that Madagascar lacked a harmonized national supply chain management system and relied heavily on international partners such as WHO, UNICEF, and the Global Fund to secure laboratory and medical supplies. Cold chain management for vaccines was in place through the Expanded Programme on Immunization, but coordination across sectors remained limited (pp. 44–45). ⁴⁴⁹ The World Bank's Pandemic Preparedness and Basic Health Services Delivery Project (2021) highlights investments in strengthening supply chain distribution systems and vaccine cold chain infrastructure, though it does not confirm the existence of a unified mechanism that is regularly exercised, reviewed, and updated (pp. 24–27). ⁴⁵⁰
No additional information was found on the website of Ministry of Public Health. ⁴⁵¹

4.3 Medical countermeasures and personnel deployment

4.3.1 System for dispensing MCMs during a public health emergency

4.3.1a Plan/program/guidelines for dispensing MCMs during a public health emergency

Score: 0

There is no evidence that Madagascar has a plan, programme, or guidelines in place for dispensing medical countermeasures (MCM) for national use during a public health emergency. The 2017 WHO Joint External Evaluation for Madagascar does not mention the existence of such a plan and recommends that the government develop a national plan with procedures for sending out MCM in an emergency (p. 33). It notes that the government has set up a Response Service for Emergencies, Epidemics and Disasters (SURECA), which has established MCM stocks for use in any emergency in all 22 regions (p.40). ⁴⁵² A report on a cyclone response in 2014 showed that SURECA plays a role in distributing MCM, but no plan can be found on the procedure, as SURECA does not have a website (p. 3). ⁴⁵³ There is no evidence of a plan, programme, or guidelines in place for dispensing medical countermeasures during a public health emergency on the websites of the Ministry of Public Health ⁴⁵⁴, the Bureau of Risk and Disaster Management (BNGRC) ⁴⁵⁵, or the Office for the Prevention and Management of Emergencies (CPGU) ⁴⁵⁶. There is also no evidence on the website of the Madagascar Drug Agency ⁴⁵⁷, or in the 'Contingency Plan 2015-2016' ⁴⁵⁸. Furthermore, the 2025 Roadmap for More Anticipatory Action in Madagascar outlines new emergency preparedness approaches (such as cash and voucher systems and technical working groups for disaster response), but does not reference any official procedures, guidelines, or plans for MCM dispensing during public health emergencies (p. 3).

4.3.2 System for receiving foreign health personnel during a public health emergency

4.3.2a Plan to receive foreign health personnel during a public health emergency

Score: 100

Madagascar has an established public plan to facilitate workforce surge in health emergencies, particularly through the national SURGE initiative launched in 2025. The SURGE initiative, under the WHO Emergency Preparedness and Response (EPR) program, aims to deploy Rapid Intervention Teams within 24 hours after confirmation of a health emergency. This plan strengthens the existing health system by enhancing infection prevention, laboratory capacity, and rapid response capabilities. ⁴⁵⁹ The EPR framework supports countries like Madagascar in preparing for, detecting, and responding to health emergencies through coordinated operational support and capacity mobilization. ⁴⁶⁰ The 2017 Joint External Evaluation (JEE) report for Madagascar identified foundational emergency response structures such as the Service des Urgences et des Ripostes aux Épidémies et Catastrophes (SURECA) and regional rapid response teams (p. 40). However, it also noted shortcomings at that time, including the absence of standardized operational procedures for workforce activation (p. 36-37), insufficient numbers of health workers especially outside urban centers (p. 31-33), and limited formal legal frameworks for mobilizing surge personnel (p. 41-42). ⁴⁶¹

4.3.2b Plan to facilitate workforce surge in an emergency

Score: 0

There is no evidence that Madagascar has a formal public plan in place defining the procedures for receiving health personnel from other countries during a public health emergency. The 2017 WHO Joint External Evaluation confirmed this regional mechanism but recommended that Madagascar establish a national plan outlining decision-making and procedures for hosting or deploying foreign health teams (p. 35). ⁴⁶² Despite the presence of national contingency frameworks under the Bureau of Risk and Disaster Management and the Ministry of Public Health, no publicly available document provides clear guidance on how foreign health workers would be integrated into domestic emergency response. ⁴⁶³⁴⁶⁴

4.3.2c Plan to redeploy existing health personnel within the country

Score: 0

There is a public plan in place that addresses the redeployment of existing health personnel within Madagascar, both geographically and by role, particularly in the context of emergency response. However, no evidence of the same is available outside the JEE.

According to the 2017 Joint External Evaluation (JEE) report, Madagascar has a Emergency and Epidemic Response Service "Service des Urgences et des Ripostes aux Épidémies et Catastrophes (SURECA)" tasked with managing health risks related to disasters and epidemics across 22 regions of the country. This service prepositions essential medicines and medical supplies regionally and supports regional mobile intervention teams (SEMoI) by redeploying personnel such as urgentists and specialists, as well as medical materials, to areas where emergencies occur. This system effectively facilitates both geographical and role redeployment of health personnel during health emergencies (p. 40-42). The JEE notes that while this redeployment system exists, gaps remain in the legal framework and formal protocols for workforce mobilization in emergencies (p. 41-42). ⁴⁶⁵ SURECA does not have a website and no additional information was found on the website of Ministry of Public Health. ⁴⁶⁶

4.4 Healthcare access

4.4.1 Access to healthcare

4.4.1a Constitutional guarantee of citizens’ right to medical care

Score: 50

The Constitution of Madagascar explicitly guarantees citizens' right to medical care, but this guarantee is based on national capacity. Article 19 recognizes the right to health and the organization of free public health care, specifying that gratuitousness is contingent upon the capacity of national solidarity. ⁴⁶⁷

4.4.1b Access to skilled birth attendants (% of population)

Score: 20.59

4.4.1c Out-of-pocket health expenditures per capita, PPP (current international $)

Score: 98.48

4.4.1d Coverage of essential health services through universal health coverage

Score: 16.67

4.4.1e Total population pushed below a relative poverty line by household health expenditure (60% of media daily per capita consumption or income)

Score: 85.13

4.4.1f Rate of mortality amenable to health care

Score: 79.05

4.4.2 Paid medical leave

4.4.2a Guaranteed paid sick leave

Score: 66.67

In Madagascar, workers are guaranteed paid sick leave for any illness that can be medically certified.

According to Article 59 of the Labour Code (Law No. 2003-044), Employees are entitled to up to six months of sick leave, during which their employment contract is suspended but salary is maintained through employer liability and social insurance benefits, provided they submit a valid medical certificate. The broad reference to “illness” means that both physical and mental health problems may be covered if they are medically certified (p. 22). ⁴⁶⁸

4.4.3 Healthcare worker access to healthcare

4.4.3a Government prioritisation of care for healthcare workers during response

Score: 0

There is no evidence that the government of Madagascar has issued legislation or a policy committing to provide prioritised healthcare services to workers who become sick as a result of responding to a public health emergency. Madagascar's contingency plan 2015-2016 provides for chemoprophylaxis for up to 10% of essential staff involved in disease response and for individuals who have had direct contact with confirmed or suspected cases. It also mentions prioritised vaccinations for essential personnel exposed to infectious diseases (p. 75). However, the plan does not specify that healthcare workers who become sick during their response duties will receive prioritised medical treatment. ⁴⁶⁹ There is no evidence of such a commitment in the 2017 WHO Joint External Evaluation for Madagascar, or on the websites of the Ministry of Public Health or the Bureau of Risk and Disaster Management. ⁴⁷⁰⁴⁷¹⁴⁷²

4.5 Communications with healthcare workers during a public health emergency

4.5.1 Communication with healthcare workers

4.5.1a Existence of system for communication during a public health emergency

Score: 0

There is no evidence that Madagascar has a system in place for public health officials and healthcare workers to communicate during a public health emergency. According to the 2017 WHO Joint External Evaluation (JEE), the country has established coordination frameworks for internal communication and communication with partners, but these require strengthening. Communication plans have been developed and tested, such as during Cyclone ENAWO in 2017 (p. 52). The national communication network, URGENCE, operates at all levels of the health system, although the JEE does not explicitly confirm that it facilitates communication between healthcare workers and public health officials. In epidemic and pandemic responses, "the health sector group has a multisectoral communication commission in which SURECA [the Response Services for Emergencies, Epidemics and Disasters, under the health ministry], BNGRC [Bureau of Risk and Disaster Management, under the interior ministry and which houses an emergency operations centre], DSV [Directorate of Veterinary Services], the Malagasy Red Cross, WHO, UNICEF, ACSQDA [the food safety agency], IPM [Pasteur Institute of Madagascar, a non-governmental medical research institute] and USAID participate, for which leadership is provided by the Ministry of Health" (p. 50). There is also a humanitarian platform for the private sector, used to coordinate private sector involvement in emergency response (p. 52). The evidence implies that these may be mechanisms which could enable communication between public health officials and healthcare workers in the private and third sectors, but there is no explicit evidence stating this.⁴⁷³ There is no evidence that URGENCE or another mechanism specifically enables public health officials and healthcare workers to communicate during an emergency from the websites of the Ministry of Public Health or the BNGRC, from the last available contingency plan, or from a wider online search. ⁴⁷⁴⁴⁷⁵⁴⁷⁶

4.5.1b Inclusion of public and private sector in healthcare communication system

Score: 0

There is no evidence that Madagascar has a system in place which specifically enables communication between public health officials and healthcare workers during a public health emergency that includes both the public and private sectors. According to the 2017 WHO Joint External Evaluation (JEE), Madagascar has coordination frameworks for internal communication and with partners that require strengthening (p. 40). The national communication network, URGENCE, exists at all levels of the health system but the JEE does not explicitly confirm that it covers communication between healthcare workers and public health officials. During epidemics and pandemics, a multisectoral communication commission involving various agencies and organizations, including those representing the private sector, operates under the Ministry of Health's leadership (p. 50). There is also a humanitarian platform coordinating private sector involvement in emergency response, suggesting these could facilitate communication across sectors (p. 52). However, no explicit evidence confirms that these mechanisms effectively support communication between public health officials and healthcare workers from both public and private sectors. ⁴⁷⁷ Information websites of the Ministry of Public Health or the BNGRC, from the last available contingency plan, and further searches reveal no clear system fulfilling this role. ⁴⁷⁸⁴⁷⁹⁴⁸⁰

4.6 Infection control practices

4.6.1 Healthcare-associated infection (HCAI) monitoring

4.6.1a Evidence of national public health system monitoring and tracking of HCAIs

Score: 0

There is no evidence that the public health system in Madagascar is currently tracking the overall number of healthcare associated infections (HCAI) at a national level. The 2017 WHO Joint External Evaluation (JEE) stated that Madagascar had no specific plan for the prevention and control of HCAI, though internal technical notes were circulated to university hospitals (CHU), which were instructed to establish HCAI committees (pp. 9-10). ⁴⁸¹ Madagascar has a national plan on handling medical waste (2014-18) which calls for increased monitoring of medical waste management and HCAI, though lack details on HCAI indicators and surveillance systems (p. 33). ⁴⁸² The JEE recommended extending HCAI control work beyond the CHU hospitals, developing national regulations, and strengthening laboratories for reliable testing and data management (p. 10).⁴⁸³

WHO Africa notes that Madagascar is working to “improve tracking of healthcare-associated infections (HAIs) and AMR across sectors,” though without confirmation of a functioning system.⁴⁸⁴ Individual hospital studies have shown some surveillance: for instance, during the COVID-19 pandemic, two hospitals monitored nosocomial infections in patients, though not in healthcare workers.⁴⁸⁵ IThere is no evidence from the JEE assessment, the health sector development plan for 2020-2024, or the website of the Ministry of Public Health that the health ministry is tracking the number of infections at a regional or national level. ⁴⁸⁶⁴⁸⁷⁴⁸⁸

4.6.1b Infection prevention and control programme

Score: 100

Madagascar has a national Infection Prevention and Control (IPC) plan in place.

In June 2023, the Ministry of Health launched a National IPC Programme with support from WHO and the AMR Multi-Partner Trust Fund. The programme includes a strategic plan, an operational plan, and a monitoring and evaluation framework, aimed at improving safety for health personnel and patients through national guidelines and multisectoral coordination (pp. 4–5). ⁴⁸⁹

The Ministry of Health has also introduced a National IPC Strategy (2024–2028), which sets out a five-year plan to prevent, reduce, and control healthcare-associated infections and antimicrobial resistance, and to establish a nationwide IPC programme supported by national prevention guidelines. ⁴⁹⁰

The IPC policy document is not available online. ⁴⁹¹

4.6.1c National plan to ensure a safe environment in health facilities

Score: 100

Madagascar has a plan to ensure a safe environment in health facilities nationally as a part of The Health Sector development plan.

The Health Sector Development Plan (Plan de Développement du Secteur Santé, PDSS) 2020–2024 identifies improving environmental hygiene, water and sanitation infrastructure, and infection prevention and control (IPC) as strategic priorities for all health facilities (p. 14, 26, 42, 44–45, 104). ⁴⁹²
National legal requirements in the Health Code (Code de la Santé, Loi n°2011-002) include mandatory measures for safe water, hygiene, disinfection protocols, and medical waste management in all healthcare structures (Art. 112–114, p. 48–49)[Health Code (Code de la Santé)]. Regular inspections and standards enforcement by health authorities are required. ⁴⁹³

The 2017 JEE states "policy for medical waste management and a national health and environment policy," and that an inspection program for hygiene exists in main hospitals in Antananarivo (p. 16). ⁴⁹⁴

4.7 Capacity to test and approve new medical countermeasures

4.7.1 Regulatory process for clinical trials of unregistered interventions

4.7.1a Requirement for ethical review before beginning a clinical trial

Score: 100

Madagascar has a requirement for ethical review before beginning a clinical trial. The 2011 Health Code, Article 122, states that all clinical trials must receive prior approval by the health minister, on the advice of an ethics committee under the health ministry (pp. 39-40). ⁴⁹⁵ A notice was issued in 2016 establishing a Committee of Biomedical Research Ethics to implement this law. The notice states: "Any biomedical research involving humans must be approved by the Ethics Committee". ⁴⁹⁶

4.7.1b Expedited approval for clinical trials of unregistered MCMs during epidemics

Score: 0

There is no evidence that Madagascar has an expedited process for approving clinical trials for unregistered medical countermeasures (MCM) to treat ongoing pandemics. The 2011 Health Code, Article 122, states that all clinical trials must receive prior approval by the health minister, on the advice of an ethics committee under the health ministry (pp. 39-40). ⁴⁹⁷ A notice was issued in 2016 establishing a Committee of Biomedical Research Ethics to implement this law. ⁴⁹⁸ Neither document mentions an expedited process for approving clinical trials for MCM for use in an emergency. ⁴⁹⁹⁵⁰⁰ The committee does not have an online presence and there is no information from the health ministry or the Medicines Agency regarding expedited approvals. ⁵⁰¹ There is no evidence of an expedited approvals process in the National Contingency Plan and on the website of Ministry of Public Health. ⁵⁰²⁵⁰³

4.7.2 Regulatory process for approving medical countermeasures

4.7.2a Existence of agency responsible for approving new human MCMs

Score: 100

The Madagascar Medicines Agency, along with the National Registration Commission, is responsible for approving new medical countermeasures for humans. Article 198 of the 2011 Health Code states that the Madagascar Medicines Agency is charged with registering medications for human use by granting market authorisation for new and imported medicines (p. 56). It also enforces laws and regulations on clinical trials, manufacture, import and placing on the market of medicines and other pharmaceutical products, and is responsible for pharmacovigilance and quality control of medicines. ⁵⁰⁴ Notice no. 28385/2015 states that the Madagascar Medicines Agency is also responsible for approving all medicines and medical consumables (including reagents, syringes, rapid tests, etc) sent by overseas donors for use in emergencies or in the framework of development aid, in order to gain customs clearance. ⁵⁰⁵ According to the website of the Madagascar Medicines Agency, its remit covers medications and parapharmaceutical products. It reviews applications for market authorisation for conformity with regulations and passes them to the National Registration Commission; then passes the Commission's conclusions to the director of the Medicines Agency for a final decision. ⁵⁰⁶

4.7.2b Expedited approval for human MCMs during public health emergencies

Score: 0

There is no explicit evidence detailing a currently established expedited process for approving medical countermeasures (MCM) for human use or a mechanism for the recognition of approval decisions taking place elsewhere specifically during public health emergencies.

According to the 2011 Health Code, the Madagascar Medicines Agency, together with the National Registration Commission, is the designated authority overseeing the regulation of health products, including MCMs, through standard marketing authorization procedures (Article 198) (p. 56). ⁵⁰⁷
Notice No. 28385/2015 outlines procedures for the approval of donated medicines and medical consumables for customs clearance but does not mention expedited pathways. ⁵⁰⁸

While Madagascar deployed COVID-19 vaccines through reliance on WHO Emergency Use Listing (EUL) and COVAX mechanisms, this response was context-specific and does not constitute a general or permanent regulatory mechanism for future emergencies. ⁵⁰⁹

The 2017 Joint External Evaluation (JEE) assessed Madagascar’s capacity to test and approve new MCMs as limited, highlighting the absence of formalized approval pathways during emergencies (p. 34). ⁵¹⁰ There is no evidence of a legal or regulatory framework establishing expedited approval or recognition of international regulatory decisions applicable across all MCMs in emergency contexts.

No other relevant evidence was found on the websites of the Ministry of Public Health or the Madagascar Medicines Agency. ⁵¹¹⁵¹²

Commitment to International Norms

5.1 IHR reporting compliance and disaster risk reduction

5.1.1 Official IHR reporting

5.1.1a Submission of IHR reports to the WHO in past year

Score: 100

Madagascar has submitted an IHR Self-Assessment Annual Report (SPAR) to the WHO for the last calendar year, with the latest submission in 2024.⁵¹³

5.1.2 Integration of health into disaster risk reduction

5.1.2a Existence of specific risk reduction strategies for epidemics and pandemics

Score: 0

Pandemics are not integrated into Madagascar's national disaster risk reduction (DRR) strategy, and there is no standalone national disaster risk reduction strategy for pandemics. The DRR policy (Law No. 2015-031) does not specifically address pandemics.⁵¹⁴ The National Strategy for the Management of Risks and Disasters 2016-2020 states that DRR should be integrated into the health sector, and all policies and plans (across all sectors) should be revised to incorporate DRR.⁵¹⁵ The Bureau of Risk and Disaster Management (BNGRC) is in charge of DRR. It has not published a DRR strategy for pandemics.⁵¹⁶ No DRR strategy for pandemics is available from the health ministry.⁵¹⁷ DRR has not been integrated into the 2015-2019 plan for the development of the health sector, though it discusses the need to improve disaster response capacity.⁵¹⁸

In 2022, Madagascar received World Bank financing to strengthen pandemic preparedness and health services delivery, emphasizing a One Health approach and implementation of the National Action Plan for Health Security 2020–2024.⁵¹⁹ WHO has also highlighted ongoing efforts to improve emergency preparedness and disease surveillance using Pandemic Fund resources.⁵²⁰ In 2024, BNGRC and partners launched a National Disaster Preparedness Baseline Assessment to improve multi-hazard risk management capacity.⁵²¹ However, these activities remain sector-specific or project-based. No standalone DRR strategy for pandemics has been identified.

5.2 Cross-border agreements on public health and animal health emergency response

5.2.1 Cross-border agreements

5.2.1a Existence of public health emergency agreements with regional neighbors

Score: 100

Madagascar is part of a regional network that addresses public health emergencies, primarily through its membership in the Indian Ocean Commission (IOC). As a member of the Indian Ocean Commission, Madagascar participates in the SEGA – One Health Network (Réseau de Surveillance Epidémiologique et de Gestion des Alertes), which serves as the health security arm of the IOC. This network was established to strengthen regional capacity to anticipate, detect, and respond to epidemics and other health threats ⁵²². According to a 2024 publication on One Health by the IOC, the network facilitates cooperation and coordinated management of health crises among member states (the Union of the Comoros, France/Reunion, Madagascar, Mauritius, and Seychelles). The document emphasizes that in the face of recent health crises in the region, including cholera, dengue, and chikungunya, "regional cooperation is no longer an option, it has become essential to anticipate and better manage these health threats" ⁵²³.

5.2.1b Existence of animal health emergency agreements with regional neighbors

Score: 100

Madagascar has established cross-border agreements regarding animal health emergencies through its membership in the Indian Ocean Commission (IOC)’s SEGA One Health Network. ⁵²⁴ The initiative, co-financed by the French Development Agency (AFD), has undergone several phases of development. From 2013 to 2017, the network expanded its scope to include surveillance of communicable diseases affecting both humans and animals under the “One Health” approach aligned with WHO guidelines. During this period, the health monitoring unit was institutionalized as a permanent technical department of the IOC. ⁵²⁵

As part of its cooperation mechanisms, the SEGA One Health Network created an online database (E-surveillance) to serve as a reporting tool for animal health across member states. Data on animal health events are entered into the platform, which is complemented by a smartphone application that enables real-time access and sharing of information. ⁵²⁶

5.3 International commitments

5.3.1 Participation in international agreements

5.3.1a Biological and Toxin Weapons Convention status

Score: 100

Madagascar is a State Party to the Biological Weapons Convention (BWC). The ICRC’s IHL Treaties Database confirms that the country has ratified the Convention, giving it full legal effect. ⁵²⁷ The BWC Implementation database also lists Madagascar among the States Parties, confirming its treaty obligations under the BWC framework. ⁵²⁸

At the national level, Decree No. 2012-833 on biosafety establishes the country’s legal framework for managing biological risks, including oversight of biotechnology and genetically modified organisms. ⁵²⁹

5.3.1b Submission of CBMs to the Biological and Toxin Weapons Convention

Score: 100

There is evidence that Madagascar has submitted Confidence-Building Measures (CBMs) for the Biological Weapons Convention (BWC) within the past three years. According to the United Nations Office for Disarmament Affairs (UNODA) CBM portal, Madagascar most recently submitted its CBM report in November 2024. ⁵³⁰

5.3.1c Submission of UNSCR 1540 reports

Score: 100

Madagascar has provided a national report in accordance with UNSCR 1540; its latest submission in the UN 1540 Committee’s records is dated 21 October 2019. ⁵³¹ The country also conducted, in 2019, a national workshop to develop its Voluntary National Implementation Action Plan under UNSCR 1540, involving multiple government ministries. ⁵³²

5.3.1d Extent of UNSCR 1540 implementation on public health emergencies

Score: 25

5.3.2 Voluntary memberships

5.3.2a Membership in global health security and/or biological weapons agreements

Score: 0

Madagascar meets only one of the three criteria, i.e. PSI. The country is listed as an endorsing state of the Proliferation Security Initiative (PSI), having subscribed to the Statement of Interdiction Principles. ⁵³³ Madagascar’s endorsement of the PSI follows its attendance at the PSI African Political Meeting and Outreach Event, co-hosted by Morocco and the United States on January 31-February 2, 2024. ⁵³⁴⁵³⁵ However, Madagascar is not a participant in the Australia Group (AG), which is limited to 43 members, mostly from Europe, North America, and Asia-Pacific. ⁵³⁶ Similarly, Madagascar is not a member of the Global Partnership Against the Spread of Weapons and Materials of Mass Destruction (GP). ⁵³⁷

5.4 JEE and PVS

5.4.1 Completion and publication of a JEE assessment and gap analysis

5.4.1a Completion and publication of JEE (or GHSA pilot external assessment) report

Score: 0

Madagascar conducted a Joint External Evaluation (JEE) in 2017 and released a comprehensive public report. No subsequent evaluations have been published in the last five years. ⁵³⁸

5.4.2 Completion and publication of a PVS assessment and gap analysis

5.4.2a Completion and publication of PVS report (past five years)

Score: 0

Madagascar has initiated a Performance of Veterinary Services (PVS) evaluation in 2025 and is developing a five-year improvement plan ⁵³⁹. No full PVS mission report has yet been published for this most recent assessment. The most recent publicly listed PVS activities for Madagascar are the initial PVS evaluation (2007) and a follow-up / gap-analysis in 2013. ⁵⁴⁰

5.4.2b Completion and publication of PVS gap analysis (past five years)

Score: 0

Madagascar has no published Performance of Veterinary Services (PVS) gap analysis in the last five years. The most recent PVS gap-update was in 2013. ⁵⁴¹

5.5 Financing

5.5.1 National financing for epidemic preparedness

5.5.1a Evidence of allocated national funds to improve capacity to address epidemic threats

Score: 100

Madagascar has not provided clear public evidence of substantial national budget allocations dedicated to improving capacity to address pandemic or epidemic threats within the past three years.

The Government has created a National Contingency Fund (FNC) as part of its disaster risk financing and insurance strategy, adopted in 2023. However, according to an IMF Staff Report (2024), the FNC remains “operationally weak,” with only MGA 2 billion (USD 450,000) allocated nationally, which the report characterizes as negligible compared to Madagascar’s high vulnerability to cyclones, epidemics, and other public health emergencies. The report also highlights that disbursement processes remain slow and underdeveloped. ⁵⁴²

Most recent capacity-building efforts have been financed through external sources. In March 2022, the World Bank approved USD 134.9 million to support pandemic preparedness and strengthen essential health services, with activities ranging from disease surveillance to health workforce reinforcement. ⁵⁴³

The State Budget documents available for 2022–2025 do not include explicit line items or allocations for pandemic or epidemic preparedness. ⁵⁴⁴⁵⁴⁵ No evidence of major domestically funded programs for epidemic response was identified in official documents from the Ministry of Health or Ministry of Economy and Finance. ⁵⁴⁶⁵⁴⁷

5.5.2 Financing under JEE and PVS reports and gap analyses

5.5.2a National budget to address gaps identified in JEE, NAPHS or GHSA roadmap

Score: 0

The JEE report highlights financial needs, and the NAPHS-related World Bank project describes substantial international funding, none provide clear evidence of dedicated national budget allocations to address health security gaps in Madagascar within the last five years or forthcoming periods.

The Joint External Evaluation (JEE) report for Madagascar (2017) identifies critical gaps in health security capacities, including financing and resource mobilization. However, it does not allocate or describe specific funding from the national budget to address these gaps. The report highlights the need for increased domestic financing but lacks detailed budgetary commitments or timelines (National Financing and Resource Mobilization section, pp. 33-35). ⁵⁴⁸

The National Action Plan for Health Security (NAPHS) document itself is not publicly available for direct assessment. However, the World Bank-supported Pandemic Preparedness and Basic Health Services Delivery Project (2021), which supports NAPHS implementation, outlines total project financing of approximately US$134.9 million, predominantly from international donors including the World Bank and trust funds. This document details budget allocations across pandemic preparedness, basic health services, and emergency response components but does not explicitly report national budget contributions over the past five years or planned future periods (pp. 7-11, 21-25). ⁵⁴⁹

There is no publicly available national GHSA roadmap explicitly describing or allocating specific national budget funding to address identified health security gaps. ⁵⁵⁰

5.5.2b National budget to address gaps identified in PVS assessment or gap analysis

Score: 0

Madagascar has no published Performance of Veterinary Services (PVS) gap analysis in the last five years. The most recent PVS gap-update was in 2013. No information regarding budget allocation or funding is available. ⁵⁵¹

5.5.3 Financing for emergency response

5.5.3a Emergency public financing during a public health emergency

Score: 100

Madagascar has a publicly identified special emergency public financing mechanism and funds to address public health emergencies and disaster situations.

According to the Decree No. 2022-1344 Establishing the Functioning and Management of the National Contingency Fund (Fonds National de Contingence – FNC), Madagascar created the FNC as a national reserve fund intended to provide rapid financing in the event of emergencies, including health crises. ⁵⁵²

The World Bank Country Report (Rapport Pays – Mondiale) identifies the FNC as part of Madagascar’s broader disaster risk-financing instruments, applicable to both climate-related and health emergencies (p. 85). ⁵⁵³ The Definitive Report No. 01/23-ADM/SR/COVID-19 (Rapport Définitif – Mars 2023) issued by the Ministry of Economy and Finance also acknowledges the FNC as an emergency response financing instrument (p. 12). ⁵⁵⁴

Furthermore, the Global Shield Madagascar Inventory Report (Rapport d’Inventaire – Global Shield, 2025) documents FNC budget allocations and operational challenges, confirming that is a pathway for emergency financing (p. 6). ⁵⁵⁵

5.5.4 Accountability for international commitments to address epidemic threats

5.5.4a Commitments to improve domestic or foreign capacity for epidemic threats

Score: 0

There is insufficient evidence that senior leaders in Madagascar (the President or ministers) have made a public commitment in the past three years either to support other countries in addressing pandemic or epidemic threats or to expand domestic capacity through financing or requests for support. The Government of Madagascar has endorsed national strategies, such as the National Action Plan for Health Security 2020–24, which outline commitments to strengthen health security (p. 14). ⁵⁵⁶ In March 2022, Madagascar also secured $134.9 million in World Bank financing to improve pandemic preparedness and basic health services delivery. ⁵⁵⁷ However, while these commitments reflect government and ministerial endorsement, the reviewed sources do not provide direct public statements from the President or individual ministers explicitly pledging support for pandemic or epidemic capacity-building, either domestically or for other countries. No additional information was found on the website of Ministry of Public Health. ⁵⁵⁸

5.5.4b Investments to improve domestic or foreign capacity for epidemic threats

Score: 100

There is evidence that Madagascar has received financing and technical support from donors to improve its own domestic capacity to address epidemic threats in the past three years, but there is no evidence that it has provided other countries with the same support.

According to the World Bank’s Pandemic Preparedness and Basic Health Services Delivery Project, Madagascar received International Development Association (IDA) financing and technical assistance beginning in 2022 to strengthen national epidemic preparedness capacities, including laboratories, surveillance systems, and the health workforce. ⁵⁵⁹ The World Health Organization (WHO) also provided technical assistance and launched appeals for donor support to address recurrent outbreaks and strengthen preparedness. ⁵⁶⁰ Madagascar further benefited from bilateral support, such as USAID’s MTaPS program for pharmaceutical systems and infection prevention, and Agence Française de Développement (AFD)’s support to the Institut Pasteur de Madagascar to strengthen laboratory and diagnostic capacity. ⁵⁶¹⁵⁶²

There is no evidence that Madagascar has supported other countries to improve capacity to address epidemic threats by providing financing or support in the past three years. No such evidence was found in WHO Project documents or publications of the Ministry of Public Health. ⁵⁶³⁵⁶⁴

5.5.4c Evidence that the country has fulfilled its full WHO contribution within the past two years

Score: 100

There is clear evidence that Madagascar has fulfilled its full assessed contribution to the WHO for the 2024 calendar year and the beginning of 2025.

The 2024 assessed obligation of USD 22,970 was fully covered by payments made on 19 and 20 September 2024. The 2025 assessed contribution of USD 22,970 was also fully paid on 22 May 2025. This confirms Madagascar's compliance with its WHO financial obligations for the past two years. ⁵⁶⁵

5.6 Commitment to sharing of genetic & biological data & specimens

5.6.1 Commitment to share data and specimens in emergency/non-emergency research

5.6.1a Sharing of genetic/biological data and materials beyond influenza

Score: 0

Madagascar has publicly available instruments that regulate the transfer of biological materials, but a single, comprehensive national policy specifically dedicated to the sharing of genetic data, clinical specimens, and/or isolated specimens along with associated epidemiological data beyond influenza is not readily there. Decree No. 2017-066 on Access and Benefit-Sharing of Genetic Resources establishes the national ABS framework for non-human genetic resources. It requires prior authorization from the national competent authority, prior informed consent, and mutually agreed terms for research and development uses. The decree includes provisions restricting third-party transfers without authorization (Article 32) and obligating reporting at the end of authorization periods (Article 25). The decree explicitly excludes human genetic resources from its scope (Article 4) ⁵⁶⁶. Decree No. 2017-066 further details the procedures for access, including the requirement for foreign applicants to collaborate with a Malagasy public research institution (Article 24), simplified procedures for non-commercial scientific research requiring only a declaration rather than full authorization (Articles 26-30), and obligations to submit detailed harvest reports at the end of the authorization period (Article 25). These measures confirm that sharing of non-human genetic resources internationally is possible, but only through regulated pathways under prior informed consent and mutually agreed terms conditions ⁵⁶⁷. A factsheet on Madagascar's ABS framework confirms these requirements and notes that authorizations are initially granted for a maximum of one year, renewable, and that any change of use requires new authorization ⁵⁶⁸. For human clinical specimens, the Ministry of Health's Standards and Norms for Medical Analysis Laboratories (2019) sets technical and procedural rules for identification, packaging, transport, conservation, and record-keeping. These standards specify that transmission of samples for analysis is only possible between authorized structures under the responsibility of the transmitting laboratory. They require triple packaging for long-distance transport, advance notification of the receiving laboratory, recording of dates and times of receipt, and maintenance of registers documenting all transfers. Confidentiality must be maintained throughout (Sections IV.3, IV.4, IV.9, IV.12) ⁵⁶⁹. While these frameworks demonstrate functional mechanisms for sharing both non-human genetic resources and clinical specimens under controlled conditions, no centralized, publicly accessible national policy explicitly outlining broad, routine sharing of genetic data and biological materials with international organizations or other countries beyond influenza was found on the Ministry of Public Health website. ⁵⁷⁰

5.6.1b Evidence of non-compliance with sample sharing element of PIP framework

Score: 100

Publicly available evidence indicating that Madagascar has not shared samples in accordance with the Pandemic Influenza Preparedness (PIP) Framework in the past two years is not readily available.

A review of WHO reports and management documents related to the PIP Framework does not reveal any explicit public statements or reports of non-compliance by Madagascar regarding sample sharing under the PIP Framework in the specified timeframe. ⁵⁷¹⁵⁷²

No other relevant evidence was found on the official website of the Ministry of Public Health of Madagascar. ⁵⁷³

5.6.1c Evidence of non-sharing of pandemic pathogen samples during an outbreak

Score: 100

Publicly available evidence indicating that Madagascar has not shared pandemic pathogen samples during an outbreak in the past two years is not apparent through general public health reporting.

There is no public information or reports suggesting that Madagascar has failed to share pandemic pathogen samples during an outbreak within the last two years. ⁵⁷⁴⁵⁷⁵

No other relevant evidence was found on the official websites of the Ministry of Public Health and the Pasteur Institute of Madagascar. ⁵⁷⁶⁵⁷⁷

Risk Environment

6.1 Political and security risk

6.1.1 Government effectiveness

6.1.1a Policy formation

Score: 75

6.1.1b Quality of bureaucracy

Score: 25

6.1.1c Excessive bureaucracy/red tape

Score: 0

6.1.1d Vested interests/cronyism

Score: 25

6.1.1e Corruption

Score: 26

6.1.1f Accountability of public officials

Score: 25

6.1.1g Human rights risk

Score: 50

6.1.2 Orderly transfers of power

6.1.2a Orderly transfers of power

Score: 25

6.1.3 Risk of social unrest

6.1.3a Risk of social unrest

Score: 25

6.1.4 Illicit activities by non-state actors

6.1.4a Risk of terrorism

Score: 75

6.1.4b Level of illicit arms flows within the country

Score: 50

6.1.4c Risk of organized criminal activity

Score: 0

6.1.5 Armed conflict

6.1.5a Presence or risk of armed conflict

Score: 75

6.1.6 Government territorial control

6.1.6a Government territorial control

Score: 100

6.1.7 International tensions

6.1.7a International tensions

Score: 75

6.2 Socio-economic resilience

6.2.1 Literacy

6.2.1a Adult literacy rate (15+ years old, both sexes)

Score: 79.1

6.2.2 Gender equality

6.2.2a UNDP Gender Inequality Index score

Score: 21.18

6.2.3 Social inclusion

6.2.3a Poverty gap at $1.90 a day (2011 PPP) (%)

Score: 0

6.2.3b Share of employment in the informal sector

Score: 0

6.2.3c Coverage of social insurance programs (% of population)

Score: 0

6.2.4 Public confidence in government

6.2.4a Public confidence in government

Score: 50

6.2.5 Local media and reporting

6.2.5a Robust, open, diverse local media and reporting

Score: 100

6.2.6 Inequality

6.2.6a Gini coefficient

Score: 57.5

6.3 Infrastructure adequacy

6.3.1 Adequacy of road network

6.3.1a Adequacy of road network

Score: 0

6.3.2 Adequacy of airports

6.3.2a Adequacy of airports

Score: 25

6.3.3 Adequacy of power network

6.3.3a Adequacy of power network

Score: 25

6.4 Environmental risks

6.4.1 Urbanisation

6.4.1a Urban population (% of total population)

Score: 65.76

6.4.2 Land use

6.4.2a Change in forest area (percentage points)

Score: 73.65

6.4.3 Natural disaster risk

6.4.3a Natural disaster risk

Score: 0

6.5 Public health vulnerabilities

6.5.1 Access to quality healthcare

6.5.1a Total life expectancy (years)

Score: 41.59

6.5.1b NCD mortality rate

Score: 50.27

6.5.1c Population aged 65+

Score: 87.4

6.5.1d Tobacco use (% of adults)

Score: 0

6.5.1e Level of adult obesity (%)

Score: 95.97

6.5.1f Age-standardised prevalence of mental health disorders (per 100 000 people)

Score: 63.14

6.5.2 Access to potable water and sanitation

6.5.2a Access to potable water

Score: 54.94

6.5.2b Access to at least basic sanitation facilities

Score: 14.88

6.5.2c Percentage of health-care facilities with no access to any electricity supply

Score: 0

6.5.3 Public healthcare spending levels per capita

6.5.3a Domestic general government health expenditure per capita (PPP)

Score: 1.15

6.5.4 Trust in medical and health advice

6.5.4a Trust medical and health advice from the government

Score: 0

6.5.4b Trust medical and health advice from medical workers

Score: 0

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