Madagascar operates through the Ministry of Public Health with a two-tiered medical system that divides sharply between private clinics in Antananarivo and limited rural infrastructure. The capital contains approximately fifteen private clinics with European-trained physicians, including Clinique des Soeurs Franciscaines and Espace Médical, both operating with diagnostic equipment and English-speaking staff. Outside Antananarivo, medical infrastructure consists primarily of Centres de Santé de Base, which are community health posts staffed by nurses with limited medication supplies and no imaging capability. Toamasina, Mahajanga, Antsirabe, and Fianarantsoa each maintain one or two private clinics with basic surgical capability, but advanced procedures require evacuation to Antananarivo or overseas. The island lacks functional ambulance service outside the capital. Medical evacuation typically routes through Johannesburg or Nairobi, with costs ranging from fifteen thousand to forty thousand US dollars depending on required medical accompaniment. All travelers should consult a physician regarding antimalarial prophylaxis, as Madagascar reports endemic transmission across coastal regions and the Central Highlands below 1500 meters elevation. Yellow fever vaccination is not required for Madagascar entry unless arriving from endemic countries in Africa or South America. The US Centers for Disease Control lists Madagascar in its malaria risk category, recommending prophylaxis for all travelers outside Antananarivo.
Pharmacies in Antananarivo operate under the Ordre National des Pharmaciens de Madagascar, with approximately two hundred registered locations in the capital displaying green crosses. Pharmacie de la Gare near Antananarivo railway station stocks European and South African medications, though supply chains experience frequent interruptions. Brand-name medications cost twenty to forty percent less than European prices, but counterfeit pharmaceuticals circulate widely, particularly antimalarials and antibiotics. Travelers requiring specific medications should bring sufficient supplies for their entire stay plus fifteen percent reserve. Pharmacies outside major cities stock limited ranges focused on antimalarials, antibiotics, and antimicrobials. Refrigerated medications including insulin remain unreliable outside Antananarivo due to power instability. The Madagascar pharmacy regulatory system does not require prescriptions for most antibiotics or antimalarials, though this creates quality control vulnerabilities. French remains the professional language in medical settings, with Malagasy used in rural clinics. English-speaking medical staff exist only in approximately five private clinics in Antananarivo.
The Malagasy Ariary replaced the Malagasy franc in 2005 at a rate of five Malagasy francs to one Ariary, though both terms persist in spoken transactions. As of 2024, exchange rates fluctuate between 4300 and 4700 Ariary per US dollar. The Banque Centrale de Madagascar issues banknotes in denominations of 100, 200, 500, 1000, 2000, 5000, 10000, and 20000 Ariary. Small transactions frequently reference the franc system, requiring division by five for Ariary equivalent. Street vendors and rural markets reject worn or torn banknotes, necessitating attention to note condition when receiving change. ATMs exist in Antananarivo, Toamasina, Antsirabe, Mahajanga, Fianarantsoa, and Antsiranana, dispensing maximum withdrawals between 400000 and 600000 Ariary per transaction, equivalent to approximately ninety to one hundred thirty US dollars. BNI Madagascar, Bank of Africa Madagascar, and BFV-Société Générale operate the most reliable ATM networks. Power failures frequently disable ATM networks for periods ranging from hours to days. Credit cards function only in approximately twenty hotels in Antananarivo and five in Nosy Be, plus three or four tour operators. Visa receives wider acceptance than Mastercard, while American Express functions almost nowhere. Foreign transaction fees from issuing banks typically add three percent to all charges.
Mobile money through Airtel Money, Orange Money, and Telma MVola dominates domestic transactions in urban areas, but tourists cannot access these services without Malagasy identity documents and local bank accounts. Cash remains essential for all tourism transactions outside luxury hotels. Euros and US dollars exchange readily at banks and official exchange bureaus in cities, with US dollars typically receiving rates approximately one percent better than Euros. The black market offers rates two to five percent above official rates but carries legal risk and counterfeit exposure. Banks in Antananarivo open Monday through Friday from 08:00 to 15:30, closing Saturdays and Sundays. Provincial banks maintain shorter hours, typically 08:00 to 12:00 and 14:00 to 15:00. Currency exchange outside banking hours occurs at some hotels at rates five to ten percent below official levels. Travelers' cheques have become essentially unusable since 2015, with only the head office of BFV-Société Générale in Antananarivo accepting them after multiple days of clearance verification.
Telecommunications infrastructure divides between mobile networks and nearly non-existent landlines. Telma, Airtel, and Orange operate GSM networks covering Antananarivo, the Route Nationale 7 corridor to Toliara, and coastal cities, with coverage deteriorating rapidly outside these zones. Mobile penetration reaches approximately forty percent of the population, concentrated in urban areas. 3G coverage exists in Antananarivo, Antsirabe, Toamasina, and Mahajanga, with 4G operational in portions of the capital since 2017. Data costs approximately 15000 Ariary per gigabyte on prepaid plans. Tourist SIM cards require passport presentation and cost 2000 to 5000 Ariary, with prepaid credit sold in denominations from 1000 Ariary upward at ubiquitous phone credit vendors marked by operator logos. Network congestion makes data connections unreliable during business hours from 09:00 to 17:00. WhatsApp and Facebook Messenger function more reliably than standard calls due to packet compression.
Internet access in Antananarivo occurs through hotel WiFi and approximately fifteen internet cafes, charging 2000 to 4000 Ariary per hour. Connection speeds rarely exceed 2 Mbps download in cafes, with frequent disconnections. Hotels in the ten to thirty US dollar range offer WiFi that functions intermittently, while hotels above fifty dollars per night provide more stable connections averaging 3 to 5 Mbps. Outside Antananarivo, internet access exists primarily through mobile data, with hotel WiFi functioning only in Antsirabe, Fianarantsoa, Toamasina, Mahajanga, and Nosy Be at success rates below fifty percent. National parks and rural areas lack connectivity entirely. Satellite phones operate legally but require registration with the Autorité de Régulation des Technologies de Communication. VPN services function without restriction, though bandwidth limitations make them impractical. The government has not implemented internet censorship, but infrastructure failures produce the same effect across large areas.
Electrical current runs at 220 volts and 50 hertz through Type C and Type E sockets, matching the French system. Power outages in Antananarivo occur weekly, lasting from thirty minutes to six hours, while provincial cities experience daily outages averaging three to four hours. Rural areas receive power intermittently or not at all. JIRAMA, the state electricity and water company, provides service to approximately twenty-three percent of the population. Hotels above twenty dollars per night in cities maintain generators, though these typically power only lighting and reception areas, not guest room outlets. Voltage fluctuations during power restoration can damage electronics, making surge protectors valuable. The capital experiences load-shedding by neighborhood on rotating schedules during dry season from May to October when hydroelectric capacity drops. Travelers requiring continuous power for medical devices should verify generator capacity and duration limits before booking accommodation.