Designing for Equity: An Evaluation Framework to Assess Zero-Dose Reduction Efforts in Southern Madagascar

Area of Science:

• Global Health
• Public Health
• Vaccination Programs

Background:

• Persistent inequities hinder universal immunization coverage, leaving many children unvaccinated.
• Madagascar faces low routine vaccination coverage, particularly in underserved regions.
• The SOAMEVA program targets zero-dose (ZD) children in sixteen southern districts.

Purpose of the Study:

• To outline an equity-sensitive evaluation design for the SOAMEVA program.
• To assess the implementation and impact of a community-based initiative reaching ZD children.
• To identify principles for equitable immunization program evaluation in fragile settings.

Main Methods:

• Integrated quantitative program monitoring and qualitative community insights.
• Focused evaluation at the fokontany (smallest administrative unit) level to capture micro-level disparities.
• Incorporated structured feedback loops with community health workers and caregivers.

Main Results:

• The evaluation design captures small-scale variations in ZD prevalence and program reach.
• Identified local barriers to immunization access and program adoption through community feedback.
• Tracked real-time adaptations to implementation strategies in diverse contexts.

Conclusions:

• An equity-sensitive evaluation framework is crucial for understanding and improving immunization programs in underserved areas.
• Community-based approaches and local insights enhance program responsiveness, sustainability, and equity.
• Eight design principles are proposed for equitable evaluation of immunization programs in fragile settings.