Impact of health system strengthening on delivery strategies to improve child immunisation coverage and inequalities in rural Madagascar

Elinambinina Rajaonarifara, Matthew H. Bonds, Ann C. Miller, Felana Angella Ihantamalala, Laura Cordier, Benedicte Razafinjato, Feno H. Rafenoarimalala, Karen E. Finnegan, Rado J.L. Rakotonanahary, Giovanna Cowley, Baolova Ratsimbazafy, Florent Razafimamonjy, Marius Randriamanambintsoa, Estelle M. Raza-Fanomezanjanahary, Andriamihaja Randrianambinina, C. Jessica Metcalf, Benjamin Roche, Andres Garchitorena

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3 Scopus citations


Background To reach global immunisation goals, national programmes need to balance routine immunisation at health facilities with vaccination campaigns and other outreach activities (eg, vaccination weeks), which boost coverage at particular times and help reduce geographical inequalities. However, where routine immunisation is weak, an over-reliance on vaccination campaigns may lead to heterogeneous coverage. Here, we assessed the impact of a health system strengthening (HSS) intervention on the relative contribution of routine immunisation and outreach activities to reach immunisation goals in rural Madagascar. Methods We obtained data from health centres in Ifanadiana district on the monthly number of recommended vaccines (BCG, measles, diphtheria, tetanus and pertussis (DTP) and polio) delivered to children, during 2014-2018. We also analysed data from a district-representative cohort carried out every 2 years in over 1500 households in 2014-2018. We compared changes inside and outside the HSS catchment in the delivery of recommended vaccines, population-level vaccination coverage, geographical and economic inequalities in coverage, and timeliness of vaccination. The impact of HSS was quantified via mixed-effects logistic regressions. Results The HSS intervention was associated with a significant increase in immunisation rates (OR between 1.22 for measles and 1.49 for DTP), which diminished over time. Outreach activities were associated with a doubling in immunisation rates, but their effect was smaller in the HSS catchment. Analysis of cohort data revealed that HSS was associated with higher vaccination coverage (OR between 1.18 per year of HSS for measles and 1.43 for BCG), a reduction in economic inequality, and a higher proportion of timely vaccinations. Yet, the lower contribution of outreach activities in the HSS catchment was associated with persistent inequalities in geographical coverage, which prevented achieving international coverage targets. Conclusion Investment in stronger primary care systems can improve vaccination coverage, reduce inequalities and improve the timeliness of vaccination via increases in routine immunisations.

Original languageEnglish (US)
Article numbere006824
JournalBMJ Global Health
Issue number1
StatePublished - Jan 10 2022

All Science Journal Classification (ASJC) codes

  • Public Health, Environmental and Occupational Health
  • Health Policy


  • health systems
  • immunisation
  • vaccines


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