Primary health care: back to basics in Madagascar.

News Primary health care: back to basics in Madagascar The name might have changed but primary health care remains a key policy of the Malagasy state. Rivonala Razafison reports on the challenges that health workers face in Madagascar. When the first batch of 1500 young health aides were dispatched in 1980 to Madagascar's villages, it was thought to herald a new era in health care for the island nation off the southeast coast of Africa. The project was the centrepiece of the country's primary health care policy, launched in 1978 with high hopes of meeting the Alma-Ata goal of health for all by 2000. The drive to improve health services was not before time. Despite declaring its independence from France in 1960 and undergoing the Malagasy Socialist Revolution resulting in the Second Republic in 1975, health care in Madagascar remained inadequate, a throwback to colonial times when it served the ruling elite, with its infrastructure and staff concentrated in the towns. In the intervening 30 years, the much-vaunted primary health care initiative has brought mixed results, making strong advances in some areas while failing to deliver in others. On the plus side, Professor Dieudonné Randrianarimanana, the cabinet director of the Madagascar Ministry of Health, Family Planning and Social Protection in the capital Antananarivo, says that the islanders have never been more motivated to look after their health as they are today. The general situation is getting better , says Randrianarimanana. Average life expectancy is 55 years; poliomyelitis is about to be eradicated; the prevalence of leprosy is less than 1 per 10 000; and infant mortality is decreasing (in 2006 the probability of dying in the first year of life was down to 58 deaths per 1000 live births compared with 98 in 1993 and 74 in 2003). The government is aiming for a 100% success rate in preventing and treating malaria, while AIDS is not a major health problem, he says, because HIV prevalence is relatively low compared with the rest of sub-Saharan Africa; an estimated 0.95% of the island's population of 18.6 million are infected. However, Randrianarimanana says Madagascar has failed to achieve the health for all by 2000 target laid down by the Alma-Ata Declaration, and estimates only 60–70% of Madagascar's inhabitants – that is those who live in regions served by roads – have ready access to primary health care. Many people still have to walk …