ArticleBMJ global health2022
Impact of health system strengthening on delivery strategies to improve child immunisation coverage and inequalities in rural Madagascar.
Article in BMJ global health, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 10 papers, 1 of them a synthesis that pooled it.
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Who cites it
10 citing papers in PubMed, 1 synthesis or guideline pooled it, 16 citations in OpenAlex.
- Tetanus toxoid vaccination coverage and associated factors among pregnant women in East Africa: systematic review and meta-analysis.BMC public health · 2025Pooled it
- Emerging Viral Zoonoses: Epidemiology, Vaccination Strategies, and Implications for Global Public Health.Vaccines · 2026Review
- Spatial distribution of full immunization and associated factors among children aged 12-23 months in Madagascar: a spatial and multilevel analysis.Scientific reports · 2026Article
- Determinants of post-campaign measles vaccination coverage in Madagascar: A geographically stratified analysis.PLOS global public health · 2026Article
- Public health surveillance of tropical diseases in Madagascar: a scoping review of population burden, intervention strategies, and health system responses.BMC public health · 2025Article
- Full vaccination coverage for children aged 12-23 months in Madagascar: Analysis of the 2021 Demographic and Health Survey.BMC public health · 2025Article
- Designing and Evaluating a Health System Resilient to Extreme Weather Events in Rural Madagascar.Annals of global health · 2025Article
- Combining OpenStreetMap mapping and route optimization algorithms to inform the delivery of community health interventions at the last mile.PLOS digital health · 2024Article
- Measuring National Immunization System Performance: A Systematic Assessment of Available Resources.Global health, science and practice · 2023Review
- Geographic barriers to care persist at the community healthcare level: Evidence from rural Madagascar.PLOS global public health · 2022Article
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Authors and funding
18 authors at 6 institutions in 4 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundTo 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.
methodsWe 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.
resultsThe 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.
conclusionInvestment in stronger primary care systems can improve vaccination coverage, reduce inequalities and improve the timeliness of vaccination via increases in routine immunisations.
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