Equity and immunization supply chain in Madagascar

Area of Science:

• Global Health
• Public Health
• Immunization Programs

Background:

• Persistent immunization inequities disproportionately affect the poorest communities globally.
• Madagascar exhibits significant immunization equity gaps, particularly impacting impoverished rural populations.
• Barriers in immunization supply chain, human resources, and service delivery exacerbate these disparities.

Purpose of the Study:

• To describe Madagascar's immunization inequities and their programmatic causes.
• To outline the country's strategies for addressing immunization barriers in impoverished regions.
• To quantify immunization system barriers in four Malagasy regions.

Main Methods:

• Two cross-sectional health facility surveys conducted in 2013 and 2015.
• Assessment of geographic access to health centers, cold chain functionality, health worker availability, and vaccination session completion rates.

Main Results:

• Significant geographic barriers exist, with 26-33% of the population living >5km from a health center.
• Acceptable cold chain functionality ranged from 52-80%, and qualified health workers were scarce (10-57% of centers).
• Vaccination session completion rates varied (65-95% fixed, 50-88% outreach), with an increase in outreach sessions over time.

Conclusions:

• Madagascar's immunization program faces substantial challenges, with the poorest populations bearing the brunt.
• Subnational immunization inequities are primarily geographic, necessitating equitable system improvements.
• Future strategies should focus on sustainable supply chain solutions, functional cold chains, and universal vaccination service access.