The territorialization of health services aims to adapt health policies to local specificities, with a view to reducing inequalities. In Madagascar, despite a context marked by deep regional disparities, this approach remains insufficiently documented. This study seeks to assess the impact of territorial health policies on maternal and child health indicators at the national level.

The study is based on secondary analysis of data from the 2021 Demographic and Health Survey. The indicators analyzed cover nutrition, morbidity, reproductive and maternal health, examined at the regional level among children under five years of age and women aged 15 to 49. Chi-square tests-standard or Monte Carlo (10,000 simulations)-with Bonferroni correction, were used to assess regional heterogeneity at a 5% significance level.

Regional disparities were statistically significant for most indicators (p<0.001). Stunting reached 51.9% [47.3-56.5] in Vakinankaratra compared to 21.7% [15.3-28.1] in Diana. Vaccination coverage ranged from 81.9% [73.1-90.7] in Itasy to 24.9% [17.6-32.2] in Sava. Institutional deliveries ranged from 68.8% [65.9-71.7] in Analamanga to 14.9% [10.12-19.5] in Ihorombe. Adolescent fertility reached 50.4% [44.5-56.3] in Sofia versus 17.5% [14.5-20.5] in Analamanga.

Health decentralization in Madagascar has struggled to reduce regional inequalities, highlighting a persistent gap between national policies and local realities. Indicators reveal significant disparities in nutrition, access to healthcare, contraception, and maternal health. The decentralized territorial communities, often deprived of resources and real autonomy, remain dependent on the central government. The lack of effective territorialization limits the adaptation of policies to local needs. A structural reform is needed, based on the genuine transfer of responsibilities, the strengthening of local capacities, and the co-construction of actions with communities.