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Introduction: Despite renewed commitment to universal health coverage and health system strengthening (HSS) to improve access to primary care, there is insufficient evidence to guide their design and implementation. To address this, we conducted an impact evaluation of an ongoing HSS initiative in rural Madagascar, combining data from a longitudinal cohort and primary health centres., Methods: We carried out a district representative household survey at the start of the HSS intervention in 2014 in over 1500 households in Ifanadiana district, and conducted follow-up surveys at 2 and 4 years. At each time point, we estimated maternal, newborn and child health coverage; economic and geographical inequalities in coverage; and child mortality rates; both in the HSS intervention and control catchments. We used logistic regression models to evaluate changes associated with exposure to the HSS intervention. We also estimated changes in health centre per capita utilisation during 2013 to 2018., Results: Child mortality rates decreased faster in the HSS than in the control catchment. We observed significant improvements in care seeking for children under 5 years of age (OR 1.23; 95% CI 1.05 to 1.44) and individuals of all ages (OR 1.37, 95% CI 1.19 to 1.58), but no significant differences in maternal care coverage. Economic inequalities in most coverage indicators were reduced, while geographical inequalities worsened in nearly half of the indicators., Conclusion: The results demonstrate improvements in care seeking and economic inequalities linked to the early stages of a HSS intervention in rural Madagascar. Additional improvements in this context of persistent geographical inequalities will require a stronger focus on community health., Competing Interests: Competing interests: Some authors are current or former employees of institutions discussed in this article, including the non-governmental organisation PIVOT and the Government of Madagascar. These affiliations are explicitly listed in the article., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To determine the accessibility of treatment and the quality of antiepileptic drugs (AEDs) in the Haute Matsiatra district of Madagascar., Methods: Cross-sectional descriptive study and interviews. Samples of 10 units of each available AED were collected, and the active ingredient was quantified by reversed-phase high-performance liquid chromatography (RP-HPLC) with photodiode-array UV detection. The quality of an AED was considered satisfactory if the quantity of active ingredient in each tablet was in the range ±15% of the average value according to the European Pharmacopeia (6th edition, 2008)., Results: The area was well served with health infrastructure but rescue facilities were poorly distributed. Available AEDs were all first-generation, and 73% were generic formulations. People with epilepsy (PWE) surveyed consulted traditional healers and most were treated with plants. PWE did not consider themselves sick but believed they were "possessed"; they consulted a doctor only immediately after a seizure, following the advice of traditional healers. The most prescribed AED was phenobarbital, costing between 0.03 and 0.12 US Dollar (US$) per 100mg. The purchase of full treatment was difficult for 77% of PWE and as a result, 39% took nothing. The quality of AEDs were considered unsatisfactory in 2.8% of cases., Conclusion: The AEDs collected in Haute Matsiatra were globally of good quality. The main limiting elements were a lack of knowledge among PWE that epilepsy is a disease, and the cost of traditional treatments., (Copyright © 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

The rarity of genital tuberculosis and the non-specificity of its manifestations lead to delayed diagnosis and the need to treat this disease at an advanced stage. We report two cases observed and treated at the Fianarantsoa Teaching Hospital: two young women (aged 22 and 33 years) discovered during work-ups for primary infertility and secondary amenorrhea. The diagnosis was established by histological examination of granulomatous tissue with caseous necrosis, pathognomonic for tuberculous. Isolation of mycobacterium by inoculation on Lowenstein-Jensen medium and culture are not available in Fianarantsoa. Chemotherapy against tuberculosis is most often effective for the disease, but fertility is definitely compromised, even though in vitro fertilization is possible in some cases.

Post-term pregnancy in the broad ligament is rarely described in the literature. A 33-year-old woman, grava 2 para 1, not followed-up during gestation was admitted at 44 weeks of gestation. The fetus was dead and in transversal position, as shown by ultrasound. A cesarean section was performed and the fetus was extracted from the right broad ligament. The placenta was inserted on the surface of the posterior wall of the uterus. Blood loss was estimated at 1200 mL and the patient received isogroup total blood. There was no major complication., (Copyright © 2014. Published by Elsevier SAS.)

Cutaneous manifestation of tuberculosis is still observed in countries with high endemicity of tuberculosis such as Madagascar. The purpose of this report is to describe a case of nodular type cutaneous tuberculosis located in the subclavian region of a 5-month-old child living in Antananarivo, Madagascar. In absence of bacteriological evidence, diagnosis was based on epidemiological, clinical and histological findings. Treatment was successful using standard antituberculosis therapy. This case illustrates the diagnostic pitfalls associated with this type of tuberculosis.