Law No. 2011-003 With Hospital Reform

Original Language Title: Loi n°2011‐003 portant réforme hospitalière

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LAW N ° 2011-003


ION 2011 - 003

wearing hospital reform EXPLANATORY MEMORANDUM

"Madagascar Hospitals, public or private, in possession of technical platforms within acceptable standards for the country, and have a status, organization and financial autonomy to ensure quality services, normal circumstances or in times of disaster to the entire population, in full respect of human rights "is the vision of the Ministry of public Health for Hospital Reform.
The law Hospital Reform, which is the subject of this Explanatory Memorandum, is the first basic text expressing the will to implement hospital reform in Madagascar. Indeed, unlike other components of the health system, Hospital Establishments have been no development program for decades. Surveys of various managers and hospital doctors led multi following findings:
• Expansion of needs and response options to the demand for care of the Malagasy society; • lack of Loison framework and lack of cultural continuity; • absence of legislation governing the organization and operation for the Hospital
Regional Reference Centres and Hospital Centers District causing a multiplication and disparity of use rudimentary texts (circular, memorandum, instructions); • inadequate organization and management modes of public hospitals
'' administered rather than managed ''; • procedural problems posed by the Public Establishment of status character
Administration (EPA) applied to the University Hospital (CHU); • disparity between the modes of organization of different types of Hospital
Institutions; • absence of a real complementarity public / private; • Lack of quality care offerings; 3

• insufficient regulatory framework applied to non-profit and private health sector; • inadequate supervision and training; • failure on the logistics plan (aging infrastructure and technical
trays, maintenance problem, ...), financially (current mechanisms have their limits), the human resources plan (number, qualification, organization of training, ...) on the plan / program planning processes. These situations have led public Hospital Establishments in a spiral of degradation. Thus, users are increasingly negative image of public Hospital Establishments. This explains the low hospital attendance. Therefore, the reform of public and private hospital sector is essential to better meet the requirements of a national health-oriented health policy for all and the requirements of the Malagasy society who demand a more just and more effective medicine . These objectives are similar to those described in the national health policy, which itself embodies the provisions of the Constitution of the Republic of Madagascar for the protection of the individual and his health (Articles 19 and 21) and the International Conventions, in especially the Universal Declaration of Human rights and the International Covenant on economic social and cultural rights, ratified by Madagascar.
This Act was preceded by the paper on Hospital Reform, officially released in March 2007 and is composed by three strategic areas: institutional reform, organizational reform and legal reform.

The implementation of this reform requires the development of a hospital bill that will serve as a reference framework for all related activities.
Hence the engagement of the work, in February 2010, following a nomination committee of the ad 'hoc development of the law on hospital reform, with participation of a consultant and the various managers in other sectors.
The content of the Act
The law on hospital reform has 5 titles composed of 116 items:
• The first title is devoted to general provisions and basic principles. There is provided a clear definition of Hospital Establishments, their tasks and obligations and the concept of Service Public Hospital (Chapter I) followed by a list of rights and obligations of users through the "Patient Charter" (Chapter II) .
Chapter III deals with the areas of national and international cooperation and partnerships for the development of the Hospital: possibility of international hospital cooperation for public and private institutions participating in the public hospital service, possibility of public partnership contract / private 4 accordance with the political

contracts, possibility of international cooperation with foreign entities of public or private law in compliance with international commitments of the state.
Chapters IV and V are devoted to the creation of two very important structures Hospital Reform: the National Agency and the Central Hospital. The first will be used primarily to control the reform and has an observatory and design strategies, the second is to implement reform itself and will have a strategic position within the Ministry of Health because it will be linked directly to the General Secretariat.
• Title II has been the subject of particular attention because of its object: the organization of the public hospital system. It consists of 7 chapters.
The first chapter gives the name of the establishments according to their location, legal, administrative and technical characteristics and their respective vocations: University Hospital (CHU), Hospital Provincial and Regional Reference (CHRP / CHRR), Hospital reference Districts (CHRD), and determines the services provided at each level: the first level (district), second level (province / region), third level (National).
The Public Hospital Establishments can be erected in Public Establishment Administrative nature involving naming Etablissement Public Health (EPS) because of their specific missions and their modes of operation. This status EPS strengthen school management autonomy, will allow a more flexible management, better understood and shared with professional health teams. The management and staff are accountable to the Board and in parallel guardianships strengthen their evaluation and monitoring mechanisms. Chapter II recalls the different Guardianship hospitals and describes the importance of the National Map Hospital and the elements to be included.

Chapter III, devoted to the functional organization says, in Article 42, the various governing bodies and management of hospitals. Their internal technical organization, in departments and services, developed in Chapter IV. The establishment of nursing and midwifery department contributes to the legitimate recognition of paramedical staff in its position and role.
The content of Chapter V concerning the organization of teaching, training and research, through the conclusion of agreements, the creation of the University Hospital Coordinating Committee and the Scientific Committee and the creation of a Foundation the research. The obligation to develop an establishment project, whose purpose is the establishment Agreement of Objectives and Means with the Ministry and / or partners, and the importance of development of the information system and evaluation within hospitals are the subject of Chapter VI. The school plan defines the strategic directions of development with resources

Needed to carry them out. This approach is intended to be participatory and consensual on all the choices made in the medical, managerial and social. Chapter VII especially recalls hospital staff plan and provides details of the incentive awards.
• Title III, with 4 chapters, is of particular importance because of its subject: the financing of hospitals. While participating in the realization of the public hospital, the hospital will strive for balance its accounts. This title III lists the financial resources and obligations of hospitals and determines the principles of managements: conservation Recipes Clean, cash advance in each EPS. Specific funding of hospital care are detailed in Chapter II: Financial Participation of Users, of Hospitalier Equity Fund Paying Third Systems. Chapter IV of this Title III defines management control and audit of hospitals.
• Title IV, consisting of 4 chapters, concerning the organization of the private hospital system. The classification and the legal regime of private hospitals in the order. The title defines and lists the cases that require authorization from the Minister for Health. It defines the possibility of involvement of private hospitals to public service and recalls the conditions of exercise of private hospitals and the control regime.
• Title V concerns the final provisions.
It should be noted that the adoption of the law on hospital reform will be followed by implementing regulations, a strong information and communication campaign, an upgrading of hospital facilities standards in terms of technical equipment and human resources, installation and implementation of new procedures and management tools and training for the entities involved in the implementation of the reform program.
The expected improvement of the law relate mainly to:
- the recognition of users' rights through the Charter of patients and hospital requirements (permanent availability of hospital care service, the mandatory treatment of all cases emergencies, continuous improvement of quality care, ...)
- the autonomy of management of Hospital Establishments by the transformation of these establishments in Etablissement Public Health (EPS)
- respect for affordable prices care for the majority of the population and the rejection of exclusion by the care of the poor in the Hospital of equity funds,

- Recognition of rights and the benefits of hospital personnel, - the development of training and research in hospitals - securing customers by strengthening regulations
opening and conditions 'the private hospital sector exercises.
This is the purpose of this Act.

ION 2011 - 003

wearing hospital reform
The Congress of the Transition and the High Council of the Transition adopted in their respective session dated 24 May 2011 and 27 May 2011, the law which reads as follows:


HOSPITAL PUBLIC SERVICE Article Premier.- This Act applies to all Hospital Establishments of Madagascar.
Article 2.- Hospital Establishments are health structures that ensure: - diagnosis, treatment and monitoring of patients; - Hospitalization of patients when their condition warrants.
The quality of care for patients should be a key objective for all
hospital and respect of continuity of care, following their admission or their accommodation, in conjunction with other structures care and health professionals.
Article 3.- Hospital Establishments include:
- Hospitaller Public Institutions classified according to legal and technical criteria specified in Articles 29 and 30 of this Act;
- Of Hospital Establishments Private for-profit or non-profit purpose; - Hospital Establishments of the Armed Forces.

Article 4. The public hospital service guarantees for equitable access to care. He is required to accommodate everyone, day and night, emergency if the patient's condition or injury warrants. The public health service can not discriminate between patients regarding care.
Article 5. The Hospitallers Public Institutions, the Private Hospital Establishments and Hospital Establishments of the Army, participating in the public hospital service must have adequate means to deliver quality care. These establishments are required to support their patients are regularly referred or should direct them, under their medical responsibility, to the nearest facility with the required skills.
These establishments provide to patients curative, preventive and rehabilitation that require their state.
Article 6. Any establishment, having received a referred patient, address the practitioner who referred a summary of the case.
Article 7. In addition to the tasks defined in Articles 2 and 4 of this Act, the public hospital service contributes to: - the implementation of all activities of preventive medicine and health education,
is within the scope of public health priorities defined by the Ministry of health;
- And postgraduate university education in the health sciences; - Continuing education of medical staff; - Initial and continuing training of paramedical staff; - The health sciences research; - The organization of emergency medical aid in conjunction with the relevant entities; - The management of the prison population in conditions laid down by regulation
Article 8. Participation of Hospital Establishments Armed
to the hospital public service is defined by regulation.

Article 9.- The Hospitallers Public Institutions, the Private Hospital Establishments and Hospital Establishments of the Army, participating in the public hospital service, are required to ensure in exceptional circumstances, a minimum service enabling them to fulfill their obligations of care vis-a-vis patients.
Article 10. In case of force majeure, medical, paramedical, administrative and support can be requisitioned by a decision of the Minister of Health. The force majeure is recognized when: 8

- A situation leads to the interruption of the normal functioning of hospitals likely to endanger the lives of patients;
- A situation imposes a humanitarian emergency. Article 11.- In compliance with ethical rules applicable to them, the practitioners
hospitals should provide information to persons in care by taking into account their level of understanding.
Paramedics must participate in this information in their field of competence and in accordance with their professional rules.
Article 12. Each hospital staff held in strict respect of medical and professional secrecy. The confidentiality of information it holds on those admitted must be protected in accordance with applicable laws, including those relating to the rights and protection of people and the health code.
However, pursuant to Article 69 of Law No. 2007-023 of 20 August 2007 on the rights and protection of children, in case of discovery abuse signs in a child, the medical staff must draw up a forensic report. To this end, it is no longer bound by professional secrecy.
Article 13. A medical file should be made for each supported patient. This file is archived and retained by the institution for a period of at least ten years. The characteristics of different types of file and archive conditions are determined by regulation.
Article 14.- The patient's right to free choice of doctor and hospital of its establishment is a fundamental principle.
No limitations to this principle may be submitted except in cases of consideration of technical capabilities for hospital facilities, their organization, their pricing method, the support arrangements in the context of a third-party payment system constraints related to geographical access as well as transportation.
Article 15. Each institution must write a '' Patient's Charter ', specifying the rights and obligations of the patient vis-à-vis the establishment and personal, from a general framework through regulatory.
Article 16. Any physician who prescribed the hospitalization of a patient in a hospital establishment must have access, on request, the information contained in the said patient record. 9

Any doctor, who admitted a patient in her hospital work, shall have access, with the agreement of the said patient, the information contained in the medical record held by another public hospital property, or private armies.
Article 17. All hospitalized patients have the right to obtain, on demand or through a doctor of his choice, the information contained in his medical records.
Article 18.- The Hospital Establishments participating in the public hospital service
can form groups of inter-hospital cooperation to jointly manage common services enabling them to improve the quality of their services.

The inter-hospital cooperation groupings have legal personality and are run by a committee of Member Institutions directors. The terms of organization and operations are set by regulation.
Article 19. As part of their development, the Public Hospital Establishments are authorized to enter into partnership public / private agreements in accordance with the statutes of each institution and legislation.
The procedure and the specifications relating thereto are set by regulation.
Article 20.- As part of the fulfillment of their mission, the Hospital
Institutions can participate in international cooperation activities with foreign entities of public or private law.
In conducting these activities, they can sign agreements in accordance with
legislative and regulatory provisions in force and the international commitments of the state.
Article 21. Donations of equipment, consumables and pharmaceuticals can only be accepted in accordance with the regulations including conditions for accepting donations secured by the Ministry of Health and in accordance with the rules force or with entities in donor countries.
Article 22. As part of the implementation of hospital reform, it is created with the Ministry of Health Hospital a National Agency, having essentially the following missions:

- Pilot hospital reform and monitoring its implementation; - Be an Observatory for the implementation of the new statutes of the Hospitallers
Public Institutions and related bodies; - Be an Observatory hospital system for analyzing, monitoring and evaluation of
hospitals in support of the single Central Directorate created; - To conduct strategies to develop design studies; - Give opinions at the request of the Minister of Health, especially on major issues of hospital
national policy.
Article 23. The status of the National Agency Hospital, composition and manner of appointment of members, powers and operating methods are set by regulation.

CENTRAL MANAGEMENT Article 24. A Central Branch was created to ensure on one hand the continuity of public hospital system reform and private equity and also ensure supervision effective technique on all Public Institutions and Private hospitals.
Article 25.- The Central Directorate reports directly to the General Secretariat of the Ministry of Health.
Article 26.- The Central Directorate's main mission - to implement hospital reform with the support of the Hospital National Agency; - Ensure the implementation of regulations, harmonization of standards and their
supervision; - For monitoring, evaluation and control of Public Institutions and Private Hospitals.
Article 27.- The organization of this management as well as its operation and
functions are set by regulation.

Article 28.- The Public Hospital Establishments are referred
University Hospital (CHU), Hospital Centres Provincial or Regional Reference (CHRP / CHRR) and Hospital District Reference (CHRD) according to their location, the legal, administrative and technical.


Their main objective is the realization of the public hospital service and are subject to
control of the competent organs of the State.
Article 29. The first level of Hospital Establishments Publics provide priority of primary care services, general surgery, obstetrics and emergency care. They consist hospital centers District Reference (CHRD).
The second level Hospital Establishments Publics provide medical services, general surgery, obstetrics, specialty, emergency and specialized care for medical and surgical character. They consist hospital centers of Regional and Provincial Reference (CHRR / CHRP).
The Public Hospital Establishments third level have a vocation to care that spans the entire country, due to their high specialization in medicine, surgery, obstetrics, and specialties. They are intended to provide practical training to university and post-graduate and research. These are the University Hospital (CHU).
Article 30.- The Public Hospital Establishments can be erected in public institution of administrative nature bearing the designation of Etablissement Public Health (EPS) because of their specific missions and their modes of operation.
The Public Institutions of Health (EPS) are legal persons of public law with legal personality and with administrative and financial autonomy. They provide public service missions for humanitarian purposes.
Article 31. The University Hospital (CHU) and the Hospital Regional Reference Centres and Provincial (CHRR / CHRP) are erected in Public Institutions of Health (EPS) with the prerogatives and obligations attached to it.
Article 32.- The Hospital District Centres of Reference (CHRD) retain their status as related services, under the administrative authority, technical and financial, of the Ministry of Health.
Article 33.- The Hospital District Centres of Reference can be erected in Public Institutions of Health, by regulation, after consulting the National Agency Hospital.
Article 34. The fundamental principles of autonomy of Public Institutions of Health are specified in the regulations concerning the statutes, organization and operation especially in terms of financial resource management, logistics resource management and human resource management .

Article 35.- The principle of contractual staff recruitment by the Health Public Institutions is accepted but the decision is the responsibility of the Board as part of its powers and according to the needs and financial possibilities of each Establishment.
Article 36.- The Public Institutions of Health are under the financial supervision of
Ministry of Finance and Budget and under the administrative and technical supervision of the Ministry of Health.
The exercise of this dual supervision is provided by the representatives of the ministries concerned in their implementation Region. Other Hospital Establishments Public services remain attached to the Ministry of Health.
Article 37. The reporting and functional relations with the various supervisory authorities are specified by regulation.

The authority of administrative and technical supervision guarantees the performance of its tasks by the Public Hospital Establishments, the regular operation of administrative and management bodies, the fulfillment by each Public Hospital Establishment of organic laws, statutes , contracts and agreements and hospital assets.
Article 38.- The articulation and complementarities between Public Hospital Establishments, including the reference and against reference are specified by regulation.
Article 39.- The hospital board is a subset of the national health card. It determines globally without distinguishing the public sector and the private sector, structures and resources to the management of hospital care, as well as their location.
Article 40.- The precise hospital map - coverage areas and distribution of hospitals; - The categories and classification of establishments; - For each health region, the nature and extent of facilities and activities
care necessary to meet the needs of the population, based on standards relating to: 13

O the number and nature of medical, surgical, specialty and medical-technical services
and the number of beds; o the list of biomedical equipment and medical-technical minimum for each
structure and the list of equipment and facilities from a technical level, the acquisition is subject to prior authorization of the administrative and technical supervision;
O the human resources needed for the development of theoretical staffing tables for each structure;
O the appropriate logistical resources.
Article 41.- The hospital map, updated regularly and at least every five years, is fixed by decree of the Minister of Health after consultation with the National Agency Hospital.
Article 42.- The administrative and management Public Hospital Establishments are:
For Public Institutions of Health (EPS) - the Board of Directors, deliberative body that
sets the general policy of the institution; - The management of the establishment, the executive body, which provides management and general conduct
of the institution; - The Advisory Bodies compounds of the Medical Commission of Establishment (CME)
called University Hospital Medical Committee in the University Hospital of the Paramedical Care Commission and the Establishment Committee.
For Public Hospital Establishments not having the status of EPS: - the Head of School defines and executes his team chieftaincy
management of the institution; - The advisory bodies of the Management Board of the Medical Commission and
Care and the Establishment Committee.
Items 43.- The rules for appointing members and missions, functions and operating procedures of deliberative and consultative bodies are fixed by regulatory channels.

Article 44.- The Public Hospital Establishments are organized into departments and services.
Services CHU, CHRP and CHRR are grouped into administrative departments, medical, medical-technical and paramedical care.
The CHRD are organized in administrative services, medical, medical technology and care.
Article 45.- The terms and conditions of appointment of officials, organization and operation of departments and services are set by regulation.

Article 46.- The Public Hospital Establishments can offer various categories of hospitalization for patients who correspond to different pricing. The quality of medical and paramedical care is the same for all users, whatever their class hospital.
The classification procedures, organization, pricing and hospital management categories are established by regulation.
Article 47.- The day hospitalization and home hospitalization are alternatives to traditional hospitalization whose terms are set by regulation.
Article 48. Any patient with a medical emergency, life-threatening, has any immediate and appropriate therapeutic management, without being required him an advance payment.
The emergency situation does not relieve the patient of the fulfillment of financial formalities.
Article 49. Except in cases of emergency, any patient can be admitted to a public hospital and receive care without the prior completion of administrative and financial formalities prescribed by regulation.
Article 50. Any patient who has been supported by a hospital is the responsibility of it until he was allowed to go home or transferred to another hospital with the skills required to ensure continuity of care.
Any patient who asks out of a hospital against medical advice must sign a waiver. If denied, the minutes, which is authentic until proven otherwise, is set by a prison doctor.

Article 51.- The Public Hospital Establishments involved in the initial and continuing
provided to various health professions, including hosting internships and offering guidance.
Article 52. - The Public Hospital Establishments are entitled to all or part of their clinical services and medical technology, to conclude agreements with schools and public and private training institutions, teaching and research sector health.
The agreements specify the organizational modalities and reciprocal obligations between the Hospital Establishments concerned and each institute or training and research schools that provide education for health professionals.
The standard specifications developed by regulations, defines the legal responsibilities, administrative and technical establishment, staff and learners with respect to patient care activities. He also said trainers intervention conditions institutes and schools involved to achieve framing.
Article 53.- The University Hospital and other accredited Public Hospital Establishments pass university hospital agreements with the Faculties of Health Sciences.
These conventions developed between the Ministry of Higher Education and Scientific Research and the Ministry of Health, based on a framework agreement set by regulation, specify in particular the rights and duties of teachers involved in schools. They also determine the organization of the functions of teachers and researchers, responsibility and working conditions.

Article 54.- In the University Hospital, he created a '' University Hospital Coordinating Committee 'comprising representatives of the institutions that have signed an agreement with the Faculties of Health Sciences, representatives of the Ministry of Higher Education and Scientific Research and the Ministry of Health.
The composition, terms of organization and functioning of the Coordination Committee and its powers, including cases where its advice may be required, are laid down by regulation.
Article 55.- A scientific and ethics committee is established in each University Hospital, in agreement with the Faculty of Health Sciences, following the conditions laid down by regulation.
Article 56. To promote research, this Act authorizes the creation of a Foundation for Research. Its organization and operation will be set by regulation. She inspires and respects the guidelines of international declarations and conventions on health research and the environment.

Article 57.- The Public Hospital Establishments are required to develop a
of Hospital Establishment Project (CDB) and submit it to the validation of the Boards of Directors for Public Institutions of Health and approval the Ministry of Health.
For Hospital District Centres of Reference, unorganized Etablissement Public Health, following the opinion of the Management Board, the Hospital Establishment Project is sent to the Ministry of Health for approval.
Article 58. The Draft Hospital Establishment defines the objectives of the institution in the medical, paramedical care, reception of patients and their families, management, information system, social policy, health and safety, training and research.
It must be compatible with the National Health Policy and the National Policy Hospital. It determines the means and resources to achieve the objectives.
Article 59.- The hospital project is based on the development project of establishing which groups all the master plans (infrastructure, equipment, computer) programmed for periods of ten (10) to fifteen (15 ) years.
Article 60.- The procedure for the development and implementation of the hospital project and the eligibility criteria for the signing of contracts of objectives and means are fixed by regulation.
Article 61. In respect of confidentiality and patient rights,
Public Hospital Establishments create or develop an information system to have knowledge of the activities, costs and impact of supply of hospital care.
This hospital information system is integrated into the national health information system. The modalities of this integration are fixed by regulation.
Article 62.- All Public Hospital Establishments implement an evaluation policy of their activities to ensure continuous improvement in the quality of care and efficiency.

The implementation of this assessment is subject to an annual report by the National Agency Hospital and addressed to the Minister of Health.

Article 63.- The Public Hospital Establishments developing their IT resources in order to have access to networks and medical and scientific databases, national and international, with the support of the National Agency Hospital and the Central.
STAFF RULES Article 64.
Public Hospital Establishments staff includes: - members of staff of the status of the civil service; - Agents' unframed '' of the state; - Teachers of the Faculties of Health Sciences; - Contract staff full-time or part-time governed by the Labour Code; - Officers made available to the institution by the Local Authorities
Decentralized (region, district); - Officers made available to the institution in the context of partnerships or
cooperation agreements.
Article 65. Any officer of Public Service stationed in a Public Institution Hospital
is intended to be assigned or appointed during his career, to other functions.
Any agent assigned to a Hospital Public Establishment is entitled to continuous training, development and specialization. The conditions are specified by regulation.
Article 66.- The Armed Forces of health staff can be detached in
Public Hospital Establishments. Employment and secondment conditions are set by a ministerial decree of the Minister
for Health and the Minister of the Armed Forces.
Article 67.- The Central Directorate set up in collaboration with the Directorate of Human Resources
of the Ministry of Health human resource development policy focused on recruitment planning, improved training the establishment of a special system of hospital staff and to the improvement of different bodies of existing health professions and create. The texts governing the various bodies are made by regulation.

Article 68.- The Public Hospital Establishments are represented in the various human resources management commissions. The obligations and rights of the staff of Public Hospital Establishments are those set by the laws and regulations.
Article 69.- The Public Institutions of Health develop an individualized system of human resource management while remaining in line with that of the Ministry of Health.
Article 70.- The medical staff of the Civil Service working in the Public Institutions of Health may be authorized to practice personalized activities outside its hour of work and outside their institution assignment, respecting the principle of full employment enacted by the General staff Regulations and if the performance of the public hospital service is not precluded.
Definition and manner of exercise custom activities defined by regulations.
Article 71.- Each Public Health Establishment is implementing an incentive policy for its staff to the results of the year.
Article 72.- The terms of organization of incentive in Public health establishments are the responsibility of the Boards under rules laid down by regulation.
Article 73.- Each Hospitalier Public Establishment, unorganized Etablissement Public Health, sets performance incentives and other non-statutory benefits for staff in compliance with the general rules for allocating and distributing fixed by regulation .

The amount of these bonuses and other benefits after advisory opinion of the Management Board shall be registered in the institution's budget.
Article 74.- The Public Hospital Establishments cover and have all of their resources generated by their activities and those that they are affected by subsidies or credits granted by the state.

Article 75.- The funds allocated to the Public Institutions of Health are deposited on a
deposit account opened in their names with the Treasury.
The Public Institutions of Health are authorized either by the texts establishing them either by order of the Minister of Finance and Budget, to submit their own recipes in bank accounts opened in their names with commercial banks of their choice.
Article 76.- The Public Hospital Establishments unorganized Public Health Institutions are state services. Their operating and investment credits are included in the General State Budget.
These establishments can create trust accounts in order to directly use their revenue, in accordance with Articles 33 and 34 of the Organic Law No. 2004 -007 of 26 July 2004 on the Laws of Finance. Operations performed on these financial statements follow the same procedures as those of the General State Budget. The creation of conditions of that trust account and special employment provisions of the deposited funds are specified by regulation.
Article 77. The financial resources of Public Hospital Establishments are made through: - operating grants and / or investment granted by public or private entities
; - Special grants (contracts of objectives and resources); - Products of the tariffed services provided by designated revenue
of the Clean Establishment (RPE); - The sale of products of medicines and pharmaceutical supplies; - The loans authorized by the regulations in force; - Donations and legacies accepted; - Other resources including those made in the form of direct staffing
equipment or in the form of pharmaceutical products and consumables by the State or the Communities.
Article 78.- Expenses Public Hospital Establishments focus on the following expenses: - operating expenditure of the institution; - Expenditure planned under investment operations; - Expenditure on training, education and research; - Expenditure on indigent patients the care is charged to the Fund
Equity Hospital following a procedure laid down by regulation; - Any expenditure on contractual labor expenses; - Unforeseen expenses related to emergency or disaster situations.

Article 79.- In addition to the individual and direct payment prior to any act or medical examination
alternatives to health financing are to be developed.
Article 80.- The user fees (PFU) remains the rule. However, from a better cost analysis and new pricing policies, the Ministry of Health should promote, nationally and at each Hospitalier Public Establishment, the support mechanisms to make available to all the proposed health care provision.

Article 81.- It is created at each hospital Etablissement Public a Hospital Equity Fund. Its operation should enable a sustainable and efficient management of patients recognized as poor before or during their stay in the Public Hospital Establishments.
The origin of the funds that supply the Equity Fund Hospital, the administrative procedure and financial use and control of the funds are set by regulation.
Article 82.- insiders payers systems and financed by technical and financial partners must, before their implementation, make the necessary and sufficient guarantees their sustainability beyond the initial funding provided.
Article 83.- Pursuant to this Act, the State undertakes to encourage and promote the creation of any national structure, regional or local public or private third-party payer for-profit or nonprofit, meeting demands foresight and mutualisation.
Article 84.- The Public health establishments are subject to the rules of public accounting
, characterized by separation function of officers and accounting.
Article 85.- The rules of budgetary and accounting management of Public Hospital Establishments are set by regulation. The regulations relating lay down the conditions for conservation and use of own revenues and specify the procedure for creating and using a cash advance in each Public Health Establishment and the Hospital District Centres of Reference maintained as state services.
Article 86.- The budget of Public Institutions of Health provides all of their income and their expenses and is presented as a program budget.
The budget of Public Institutions of Health prepared by the authorizing officer is communicated to notice in Financial Control, and then presented to the Board. He then referred to his 21

Final form by the Financial Controller and approved by the technical and financial supervision. The approved budget is notified by authorizing the Accountant and Financial Control.
Article 87.- The Accounting Standards for Public Institutions of Health, called Hospital Accounting Plan, including the list of accounts and operations of each of them is adapted to the needs and importance of the institution which after respective opinions of the Superior Accounting Council and the Court of Auditors, is approved by the Public Accounting Directorate.
Article 88.- In the Public Institutions of Health, the Director exercises the budget officer function of the institution. Secondary officers may be appointed by the statutes governing the establishment. The officers prescribe the implementation of revenue and expenditure. For this purpose, first, they observe the rights of public bodies, liquidate, ordonnancent and implement recovery revenues, and secondly, they commit, liquidate and authorizing expenditure.
Article 89.- The Accountant Public Institutions of Health is appointed by decree of the Minister of Finance and Budget. It is responsible for:
- the management and collection of revenue orders issued by authorizing officers; - Control and payment of expenses on order from accredited officers; - Custody and conservation of funds and assets belonging or entrusted to the establishment
; - The handling of funds and movements from accounts; - The retention of supporting documents of transactions and accounting documents;
- The bookkeeping accounting position.

In Public Hospital Establishments unorganized Public Institutions of Health, revenue collection and payment of certain expenses for urgent, specific or low value are provided respectively by commissioners of revenue and imprest administrators regularly appointed and authorized to that effect. These managers do their transactions on behalf of assignees public accountants.
Article 90.- The Public Hospital Establishments are subject to the general rules for the award of the tender documents markets. CHAPTER IV CONTROL

Article 91.- The management control and audit of Public Hospital Establishments
is assured by state supervisory bodies and the various supervisory bodies.


Article 92.- The Private Hospital Establishments care are clinics, polyclinics and private hospitals.
The clinic is a facility that is practiced only one medical specialty, the polyclinic and the private hospital are institutions which are practiced several medical specialties.
Article 93.- The Private Hospital Establishments are for-profit businesses or nonprofit.
Article 94.- shall be recognized private non-profit hospitals created by: - ​​NGOs, pursuant to Article 2 of Law No 96-030 of 14 August 1996 on the special regime
NGOs in Madagascar; - Associations, Malagasy and foreign, declared "associations of public utility
" in accordance with Articles 12, 13 and 14 of Law No. 60-133 of 3 October 1960, amended by Law No. 75-017 of 13 August 1975 on general rules governing associations;
- Religious denominations.
To this end, they sign an agreement with the Ministry of Health says that the mutual obligations to respect.
The terms and conditions of developing this Convention shall be established by regulation.
Article 95.- The technical supervision of the Private Hospital Establishments is exercised by the Ministry of Health.
Article 96.- Apart from obligations relating to authorization procedures and technical supervision established by this Act and any requisition measures prescribed by regulation, the Private Hospital Establishments under private law.

Article 97.- The following are subject to authorization by the Ministry of Health related projects:
- The creation, extension, conversion or total or partial cancellation, of all
Private Hospital Establishment and the consolidation of several such establishments;
- The acquisition and installation of heavy equipment for the production of high-tech and expensive care activities including the list and characteristics are specified by regulation.
Article 98.- The authorization referred to in Article 97 above is granted when the
project is consistent with the objectives of the national health policy and meets in the health region of implantation, the needs of people as defined by the national health card and hospital card under this law.
The administrative arrangements, technical terms and references for quality and competence of medical personnel and caregivers constituent of the permit application are laid down by regulation.
Each permit application is subject to the opinion of the National Agency Hospital.

Article 99.- The authorization is given before the start of work or installation of equipment or the implementation of health care activities.
When given to a natural person or a legal person of private law, it can not be sold before the start of work or installation of equipment or the implementation of health care activities.
Article 100.- Authorization to open and functioning is subject to the positive outcome of a technical visit whose terms are set by regulation.
Article 101.- The validity of the authorization is subject to the results of inspections for care activities, facilities, and equipment concerned by the competent Ministry in charge of health services.
Article 102.- Any authorization lapses if the operation has not allowed the subject of an execution beginning in the period of one year, with possible extension of one year.
The extension is requested by the recipient at least three (3) months before the expiry of the deadline for the execution time of the proposed project. They expire by the Ministry of Health.

Article 103.- The denials may be appealed to the administrative court.
Article 104.- The Private Hospital Establishments may be eligible to participate in the execution
public hospital at their request or that of the legal entity on which they depend, provided they undertake to respect the provisions articles of this law.
They can benefit from resources from the State or Regional and Local Authorities in the framework of specific agreements negotiated for this purpose.
Article 105.- The Private Hospital Establishments approved to conduct public hospital service missions must meet the conditions of organization and operation established by regulation. They establish a hospital project consistent with the objectives of the national health policy and with national hospital policy.
Article 106.- Admission to participate in the public hospital service is taken down by regulation after consultation with the National Agency Hospital. The admission refusal must be given.
Article 107.- Pricing rules applicable to Public Hospital Establishments are required to Private Hospital Establishments under contract for the part of their activities on the public hospital service.
Article 108.- The staff employment conditions of health, agent of the public service in the Private Hospital Establishments are determined by regulation.
Article 109.- The authorization granted to a Private Hospital Establishment may be withdrawn completely or partially if during inspection visits by the technical supervision, it is found that - patient safety is not ensured, - the minimum technical operating conditions are not met, - infringements of laws and regulations for the protection of public health
are found. The procedures and controls organization procedures are laid down by regulation.

Article 110.- After an unsuccessful formal notice, or in the event that the situation poses an immediate danger to human health, the partial or total suspension order by the Minister for Health against the institution becomes effective automatically.

Article 111.- The decision to reopen or business recovery, partial or total, is taken by the Minister for Health following positive results of a new inspection.
Article 112.- A penalty of imprisonment from six months to five years and a fine of twenty million ariary hundred million Ariary or one of these penalties:
1. Whoever, or operated without authorization a Private Hospital Establishment,
2. Whoever settles in a Private Hospital Establishment of equipment in breach of Articles 97 to 103, 3
. Anyone who ignores the partial suspension or withdrawal of the authorization provided for in Article 109.
In case of recidivism, the penalty of imprisonment without suspended sentence is always pronounced. The fine is a hundred million ariary to five hundred million ariary.
The prosecution is seized by the Minister of Health to the facts noted in the finding of a report, based on the pursuit.
Article 113.- In case of non respect of the total closure decision, the affixing of seals is made according to ordinary procedure.

Article 114.- All previous provisions contrary to those of this Act and shall remain abrogated.
Article 115.- Because of the urgency and in accordance with Article 4 of Law n ° 62-041 of 19 September 1962 on general provisions of internal law and private international law, this Act effective immediately upon publication by way radio, television or display, regardless of its inclusion in the Official Gazette of the Republic.

Article 116. This Act shall be published in the Official Gazette of the Republic of Madagascar. It will be enforced as a law of the state.
Antananarivo, on 27 May 2011


Rasolosoa Dolin RAHARINAIVO Andrianantoandro