Equity and immunization supply chain in Madagascar

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Equity and immunization supply chain in Madagascar

• Maya M.V.X. van den Ent^a   
• Andre Yameogo^b
• Eric Ribaira^c
• Celina M. Hanson^a
• Ramiandrasoa Ratoto^d
• Saholy Rasolomanana^b
• Chrysanthus Foncha^b
• François Gasse^a

Abstract

Vaccination rates have improved in many countries yet immunization inequities persist within countries and the poorest communities often bear the largest burden of vaccine preventable disease. Madagascar has one of the worlds largest equity gaps in immunization rates. Barriers to immunization include immunization supply chain human resources and service delivery to reflect the health system building blocks which affect poor rural communities more than affluent communities. The Reaching Every District (RED) approach was revised to address barriers and bottlenecks. This approach focuses on the provision of regular services including making cold chain functional. This report describes Madagascars inequities in immunization its programmatic causes and the countrys plans to address barriers to immunization in the poorest regions in the country.

Methods

Two cross-sectional health facility surveys conducted in November and December 2013 and in March 2015 were performed in four regions of Madagascar to quantify immunization system barriers.

Findings

Of the four regions studied 26–33% of the population live beyond 5 km (km) of a health center. By 2015 acceptable (fridges stopped working for less than 6 days) cold chains were found in 52–80% of health facilities. Only 10–57% of health centers had at least two qualified health workers. Between 65% and 95% of planned fixed vaccination sessions were conducted and 50–88% of planned outreach sessions were conducted. The proportion of planned outreach sessions that were conducted increased between the two surveys.

Conclusion

Madagascars immunization program faces serious challenges and those affected most are the poorest populations. Major inequities in immunization were found at the subnational level and were mainly geographic in nature. Approaches to improve immunization systems need to be equitable. This may include the replacement of supply chain equipment with those powered by sustainable energy sources monitoring its functionality at health facility level and vaccination services in all communities.