ThinkWell worked closely with the Project Implementation Unit of the Ministry of Public Health in Madagascar to understand the complexities of a maternal and child voucher system that was piloted in 18 of Madagascar’s 122 districts. ThinkWell’s developed a detailed understanding of Madagascar’s health financing system, conducted field visits to observe the voucher system in-practice, and met with health system administrators and beneficiaries. We identified strengths of the current system as well as bottlenecks to improved functioning. In addition, we suggested ways of increasing health services’ use through the voucher by reinforcing incentives for pregnant women and parents of children under five years of age. Finally, ThinkWell developed proposals to integrate the voucher system into Madagascar’s health financing scheme, with recommendations to ensure that all health financing mechanisms operate symbiotically and within the available national resource envelope.