@article{fdi:010083957,
  title = {{I}mpact of health system strengthening on delivery strategies to improve child immunisation coverage and inequalities in rural {M}adagascar},
  author = {{R}aojaonarifara, {E}. and {B}onds, {M}. {H}. and {M}iller, {A}. {C}. and {I}hantamalala, {F}. {A}. and {C}ordier, {L}. and {R}azafinjato, {B}. and {R}afenoarimalala, {F}. {H}. and {F}innegan, {K}. {E}. and {R}akotonanahary, {R}. {J}. {L}. and {C}owley, {G}. and {R}atsimbazafy, {B}. and {R}azafimamonjy, {F}. and {R}andriamanambintsoa, {M}. and {R}aza-{F}anomezanjanahary, {E}. {M}. and {R}andrianambinina, {A}. and {M}etcalf, {C}. {J}. and {R}oche, {B}enjamin and {G}architorena, {A}ndres},
  editor = {},
  language = {{ENG}},
  abstract = {{B}ackground {T}o 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. {H}owever, where routine immunisation is weak, an over-reliance on vaccination campaigns may lead to heterogeneous coverage. {H}ere, 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 {M}adagascar. {M}ethods {W}e obtained data from health centres in {I}fanadiana district on the monthly number of recommended vaccines ({BCG}, measles, diphtheria, tetanus and pertussis ({DTP}) and polio) delivered to children, during 2014-2018. {W}e also analysed data from a district-representative cohort carried out every 2 years in over 1500 households in 2014-2018. {W}e 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. {T}he impact of {HSS} was quantified via mixed-effects logistic regressions. {R}esults {T}he {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. {O}utreach activities were associated with a doubling in immunisation rates, but their effect was smaller in the {HSS} catchment. {A}nalysis 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. {Y}et, the lower contribution of outreach activities in the {HSS} catchment was associated with persistent inequalities in geographical coverage, which prevented achieving international coverage targets. {C}onclusion {I}nvestment in stronger primary care systems can improve vaccination coverage, reduce inequalities and improve the timeliness of vaccination via increases in routine immunisations.},
  keywords = {health systems ; immunisation ; vaccines ; {MADAGASCAR}},
  booktitle = {},
  journal = {{BMJ} {G}lobal {H}ealth},
  volume = {7},
  numero = {1},
  pages = {e006824 [13 ]},
  ISSN = {2059-7908},
  year = {2022},
  DOI = {10.1136/bmjgh-2021-006824},
  URL = {https://www.documentation.ird.fr/hor/fdi:010083957},
}