Equity and immunization supply chain in Madagascar.

Unlabelled: 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 world's 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 Madagascar's inequities in immunization, its programmatic causes and the country's 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 5km (km) of a health center. By 2015, acceptable (fridges stopped working for less than 6days) 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: Madagascar's 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.