[Malaria situation in Madagascar].

Malaria remains one of the major public health problems in Madagascar. For malaria, most of the eco-epidemiological facies of the African continent are found on this large island because of its geo-climatic diversity. These include the subequatorial facies on the east coast, the tropical facies on the west coast, the high-altitude tropical facies in the center and the subdesert facies in the south. In the first two facies, the stable type of malaria is encountered, where the major vectors are A. gambia and A. funestus. In the other two facies, the transmission of the disease is highly unstable yet causes deadly epidemics, principally from A. arabiensis. Malaria is even imported to a few inhabited zones situated above 1,500 m in altitude and to the centers of the large cities. The strategies of the fight against malaria consist of the following; early and correct health care of the cases throughout the country, supported by the community; drug prophylaxis for the target group of pregnant women; and eradication of adult insects in the central highlands, supported by an efficient surveillance. The utilization of mosquito bed nets impregnated with insecticide has not yet gone beyond the trial period. However, despite the efforts undertaken and the expenses run through by the national program, the fight against malaria is still far from covering the entire population. The high costs of spraying within the homes, the expanse of the country and the poor accessibility of many regions during the season of transmission, and insufficient sanitary coverage of the rural population in terms of quality and quantity, constitute the principal constraints of the fight. The current reorganization of the health service in Madagascar constitutes a favorable opportunity to establish a new approach for the fight against malaria. This is geared towards the participation of the decentralized health structures and the contribution of the community in the conception and the achievement of their respective strategies for the fight, supported by the central Service of the Fight Against Malaria. This new decentralized approach seems more appropriate to respond to the demands of the specific and selective strategies of the fight, better adapted to the different facies described above, and to render the National Program of the Fight Against Malaria more efficacious.