Article Text

Impact of health system strengthening on delivery strategies to improve child immunisation coverage and inequalities in rural Madagascar
  1. Elinambinina Rajaonarifara1,2,3,
  2. Matthew H Bonds3,4,
  3. Ann C Miller4,
  4. Felana Angella Ihantamalala3,
  5. Laura Cordier3,
  6. Benedicte Razafinjato3,
  7. Feno H Rafenoarimalala3,
  8. Karen E Finnegan3,4,
  9. Rado J L Rakotonanahary3,
  10. Giovanna Cowley3,
  11. Baolova Ratsimbazafy3,
  12. Florent Razafimamonjy3,
  13. Marius Randriamanambintsoa5,
  14. Estelle M Raza-Fanomezanjanahary6,
  15. Andriamihaja Randrianambinina6,
  16. C Jessica Metcalf7,
  17. Benjamin Roche2,8,
  18. Andres Garchitorena2,3
  1. 1Sciences & Ingénierie, Sorbonne Universite, Paris, France
  2. 2UMR 224 MIVEGEC, Univ. Montpellier-CNRS-IRD, Montpellier, France
  3. 3NGO PIVOT, Ranomafana, Madagascar
  4. 4Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  5. 5National Institute of Statistics, Antananarivo, Madagascar
  6. 6Ministry of Public Health, Antananarivo, Madagascar
  7. 7Dept of Ecology and Evol. Biology, Princeton University, Princeton, New Jersey, USA
  8. 8Universidad Nacional Autónoma de México, Coyoacan, Distrito Federal, Mexico
  1. Correspondence to Elinambinina Rajaonarifara; elinambinina{at}


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.

  • health systems
  • immunisation
  • vaccines

Data availability statement

Data used in this study are available from the corresponding author on request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Data availability statement

Data used in this study are available from the corresponding author on request.

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  • Contributors Conceived and designed the experiments: ER, AG, ACM, MHB and CJM. Collected the data: BRaz and MR. Performed the analysis: ER and AG. Wrote the initial draft of the manuscript: ER and AG. Revised the manuscript and accepted it in its final form: ER, MHB, ACM, FAI, LC, BRat, FHR, KEF, RJLR, GC, BRat, FR, MR, EMR-F, AR, CJM, BRo and AG. Act as guarrantor of the study: ER and AG.

  • Funding This study was funded by Institut de Recherche pour le Développement (Allocation de Recherche pour une Thèse au Sud (ARTS)); Herrnstein Family Foundation; NGO PIVOT Madagascar.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.