Malaria is the fourth leading cause of death and the fourth most frequent reason for health facility visits in Madagascar [NMCP 2019]. Malaria is primarily transmitted between December and April in Madagascar, and the entire population is at risk. 
The country is among the 20 with the highest rates of malaria cases and deaths – in 2021, it accounted for 1.6% of global cases and deaths, and 6.6% of malaria cases in East and Southern Africa. Between 2020 and 2021, the estimated number of cases increased by 19.5%, from 142 per 1000 of the population at risk to 170, and the estimated number of deaths increased 19.5%, from 0.36 per 1000 of the population at risk to 0.43. 
The age group most affected by malaria is children aged 6–13 years, representing 33.85 percent of cases. Children under 14 years of age accounted for more than 65 percent of malaria cases in 2019.
Since 2020, the number of malaria cases in Madagascar has persistently increased due to factors such as insecurity, poor road infrastructure, frequent stockouts, limited human resources, and the poor quality of the nets distributed in 2018.
Impacts of climate change also manifest regularly as cyclones in the western and eastern areas, and drought in the south and have negative impacts on general health outcomes and may especially impact malaria, such as when drought caused populations to flee from low-intensity malaria zones to high intensity zones.
The primary malaria parasites in Madagascar are Plasmodium falciparum and P. vivax and about 95 percent of infections are caused by P. falciparum.
The main malaria vectors in the country are Anopheles gambiae s.s., An. arabiensis, and An. funestus. Other vectors include An. coustani and An. mascarensis. Madagascar is at higher risk for introducing the malaria parasite as it is linked through trade to other countries.
An. gambiae s.l. is the predominant vector, and it has recently exhibited low- to moderate-intensity resistance to the insecticides deltamethrin and/or permethrin in five districts of the country.
Malaria in pregnancy
MIP interventions in Madagascar include the distribution of insecticide treated nets, IPTp at the health facility and community levels, management of malaria cases among pregnant women, and social and behavioural change to promote antenatal care, IPTp, net use and care-seeking for malaria illness among pregnant women.
Madagascar’s national guidelines align with the 2016 WHO ANC recommendations, which include eight antenatal contacts during pregnancy with ANC beginning by 13 to 16 weeks of pregnancy and include providing at least three doses of sulfadoxine-pyrimethamine (SP) for IPTp given at monthly intervals beginning at 13 weeks of pregnancy. The NMCP is implementing IPTp in 101 control or pre-elimination districts and aims to cover 60 percent of pregnant women with three doses of IPTp in 2022.
In 2020, the NMCP updated its treatment recommendations for uncomplicated malaria in pregnancy to allow for the administration of ACTs to pregnant women during the first trimester. A malaria communication plan has been developed to address the frequency and timing of ANC visits. The plan also calls on CHWs and health care providers to encourage pregnant women to begin ANC visits at health facilities during the first trimester.
Based on national routine health data from 2021, early ANC attendance (at <14 weeks gestational age) remained low at 26 percent. In addition, only 24 percent of women completed IPTp3. The country also implemented the TIP-TOP, which aimed to increase ANC attendance and IPTp from 2018-2021. Results from project districts showed that ANC attendance in the first trimester of pregnancy increased from 18 percent to 40 percent and IPTp3 coverage increased from 33 percent to 81 percent.
Severe malaria cases are treated with injectable artesunate followed by an oral ACT. Rectal artesunate was introduced in 2020 at the community level and in health facilities in more than 80 districts as a pre-referral intervention for children under five years of age with severe disease; however, due to recent WHO guidance (January 2022) to not extend the coverage of rectal artesunate, the NMCP decided to continue its rectal artesunate program where it is currently deployed and to pause expansion pending further deliberation by the Ministry of Health (MOH). The WHO guidance has been updated via the WHO Information Note, issued 4 July 2023.
Treatment for uncomplicated malaria includes an ACT plus low dose primaquine (for treatment of gametocytes) except among pregnant women, lactating women and in infants less than six months of age who receive only an ACT. However, low dose primaquine is not always given due to stockouts, and microscopy remains limited but is slowly being scaled up.
Madagascar’s NMSP includes use of mass drug administration during emergency situations or malaria epidemics to be delivered as dihydroartemisinin-piperaquine (DHP) in three monthly rounds to persons aged 2 months and above in the most impacted areas. In April 2022, NMCP delivered one round of MDA in a single district (Taolagnaro). Plans included delivering a second round in Taolagnaro in May 2022 as well as in 10 additional districts.
Madagascar’s case management guidelines are aligned with WHO recommendations and adapted to the local context. All malaria diagnosis and treatment in public facilities is free.
Severe malaria cases are treated with injectable artesunate followed by an artemisinin-based combination therapy. Rectal artesunate was introduced in 2020 in select districts at the community level and in health facilities for pre-referral intervention of children less than five years of age with severe disease.
For case management, the main barrier is the geographical distance between homes and health care facilities, and between primary health care facilities and referral hospitals. In addition, consultation of traditional healers can result in a delay in treatment. Moreover, 80% of the population lives below the poverty line. The socioeconomic status of households and of each individual can thus be a source of inequity in access to care.
Although diagnosis and treatment of malaria cases is free, the costs of additional treatment and the indirect costs of travel and patient accompaniment can result in a disincentive to attend health care facilities. 
Madagascar has an extensive programme of community health volunteers (CHVs), with approximately 36,000 CHVs covering the country (two CHVs per fokontany, the smallest administrative level).
CHVs conduct sensitization activities on the prevention of communicable diseases, including malaria. They also provide integrated community case management (iCCM) services, including malaria testing and treating, to approximately 4.5 million children under five years of age. 
CHVs in targeted areas have been trained on the use of rectal artesunate for pre-referral intervention of children under five years of age with severe disease. Limited supplies of rectal artesunate were distributed in remote high-burden areas in 2020. 
Madagascar plans to extend community-based case management of malaria to all age groups. This approach will be implemented in 41 districts identified as highly endemic, vulnerable and having experienced resurgence in recent years.
Madagascar has adopted the WHO multi-pronged approach to drug-based interventions. This includes preventing malaria in pregnancy through the provision of at least three doses of sulfadoxine-pyrimethamine (SP) spaced one month apart starting early in the second trimester (from 13 weeks of pregnancy) until delivery (IPTp3), and prompt and effective diagnosis and treatment of malaria during pregnancy. 
The percentage of women who received two or more doses of IPTp (PPTp2) during their last pregnancy in the last two years increased from 23% to 29% between 2016 and 2018, while those that received IPTp3 increased from 11% to 25% over the same period.
Because of the frequency of resurgence and the increase in the number of cases in the most vulnerable districts, the National Malaria Control Programme, with the support of its partners, plans to carry out a feasibility study into implementing seasonal malaria chemoprevention (SMC) in districts eligible according to World Health Organization (WHO) criteria.
Overall, ownership of insecticide-treated nets (ITNs) in Madagascar has been increasing in recent years. In 2013, the percentage of households with at least one ITN had dipped to 69% (from 81% in 2011), likely due to a period of US government restrictions in Madagascar. By 2016 and 2018, however, the percentage of households with at least one ITN was 80% and 78%, respectively. (Note that the 2018 data are from a Multiple Indicator Cluster Survey. This included districts that had not received ITNs in the mass distribution campaign, whereas the Malaria indicator surveys of 2013 and 2016 excluded those areas.)
The percentage of children under five years of age whose guardians reported they slept under an ITN the previous night increased from 62% in 2013 to 73% in 2016. (In the 2018 Multiple Indicator Cluster Survey, the estimate was 62%.) 
Severe malaria policy and practice
|Recommendation during pregnancy (prevention)|