In Madagascar, 44,000 children under the age of five die each year, according to the latest UNICEF figures . That number is the same as the population of all children five and under  in the entire Alpes-de-Haute-Provence region of France. It’s also the number of victims in the 9/11 terrorist attacks, 15 times over.
The tragedy behind the number – losing a child – most often affects families of limited means. Two groups in Madagascar are particularly vulnerable in terms of public health: children younger than five, and pregnant women.
According to the World Bank , half of all children under five experience delayed growth, “a larger proportion than in any other country in Africa.” The maternal mortality rate is estimated at approximately 498 per 100,000 live births, and the causes of death are many , including limited access to skilled staff during delivery, poor prenatal care, and lack of emergency care.
The health record is appalling, yet there is no shortage of initiatives to change the situation.
In Toliara in southern Madagascar, a school lunch project is helping to fight the problems of chronic malnutrition. The organization Les Enfants du Soleil (Children of the Sun) houses and educates street children and children from needy families. The children also receive a noontime meal in the school cafeteria. Take a look at photos of children who benefit in this French-language YouTube video:
Other programs target specific problems such as sickle-cell anemia or malaria. The organization LCDMF  (the initials stand for Fight Against Sickle-Cell Anemia in Madagascar) works to make the population more aware of this genetic disease affecting 2 percent of the Madagascan people. In the following video, the team leaders of LCDMF describe the past activities of the NGO and its objectives for the next three years. Two of their objectives for the upcoming years are to give better access to antibiotics for sickle-cell anemia patients and to convince Malagasy political leaders that sickle-cell anemia ought to be included in the nation's public health priorities:
In an open letter to Prime Minister Malgache Kolo Roger, LCDMF stressed the importance of treating this problem, especially in isolated regions without modern health facilities:
Ce problème crucial de santé publique qui affecte de manière dramatique les plus nécessiteux dans une région avec près de 20% de prévalence où un enfant sur cinq souffrant d’un syndrome drépanocytaire majeur est susceptible de ne pas survivre au-delà de l’âge de 5 ans, ne peut plus souffrir de demi-mesures. Il illustre à lui seul, parce qu’il s’agit d’une maladie transversale intéressant toute les spécialités médicales, l’exigence d’une prise en compte urgente de votre part de ces logiques de santé de proximité.
This is a critical public health problem that has a dramatic impact on the neediest inhabitants in a region with nearly a 20 percent disease rate and where one out of five children with major sickle-cell anemia is not likely to survive past the age of five. The problem can no longer be handled with half measures. Because sickle-cell anemia is cross-disciplinary and involves all medical specialties, this disease alone illustrates how essential it is for you to immediately take stock of the healthcare situation in our backyard.
Much remains to be done
Another area with a pressing need for action is maternal health, due to rapid population growth in Madagascar. For example, one out of five married women who wishes to space out or limit pregnancies has no access to family planning services (19 percent), and the abortion rate is estimated at one out of every 10 live births, according to the Madagascar National Institute of Statistics (INSAT) and the United Nations Fund for Population (UNFPA).
Despite these efforts, Madagascar is faced with certain weaknesses that hinder improvement in health indicators. The source of poor and uneven health outcomes lies in the disparities in household incomes and physical access to health services. Consequently, nearly one in four people (23 percent) with an illness did not seek care at a health center because they could not pay for it.
Availability of medication is also a real problem because the systematic failures in drug management and inventory tracking as well as distribution logistics hamper proper distribution of medications. As a result, the wealthy use health services four times more often than the poor: 40.9 percent of total expenses in this sector were attributed to the wealthiest fifth, whereas 10.1 percent were paid by the poorest fifth, according to the World Bank.
Experts agree that the need for action is urgent. UNICEF  says vaccination and newborn diet monitoring are necessary to reduce infant mortality. To improve the public health situation overall, the priorities should be:
- Strengthen nutrition programs targeting the most vulnerable groups, and their access to adequate nutrition;
- Enhance efficiency of budgetary expenses;
- Improve management of healthcare human resources;
- Introduce risk-free delivery kits;
- Bring doctors back to health centers in rural areas.
The situation is dire but not desperate, at least not yet. The proposed policies can be readily implemented if given the political will. The Malagasy children have waited 50 years for their collective health to be at the top of the national agenda. It is high time authorities are reminded that no respectable country would tolerate the obliteration of its future in such a manner, 44,000 times a year.