Madagascar’s Expanded Immunization Program (EPI) has been central to the country’s public health strategy since its launch in 1976. By the early 2000s, the program faced a critical turning point: how to keep vaccines accessible while managing rising costs and improving national health outcomes. This challenge led to the development of Madagascar’s Financial Sustainability Plan for EPI, covering the period from 2003 to 2013.
During this decade-long effort, Madagascar committed to expanding vaccine coverage, introducing new vaccines such as Haemophilus influenza B (Hib), and securing sustainable funding. Below, we explore the country’s health indicators, vaccination progress, and strategies for sustaining immunization efforts, providing insight into how Madagascar tackled these challenges.
Madagascar at a Glance
In 2003, Madagascar had an estimated population of 17.4 million, with nearly 3 million children under five years old—the primary focus of the country’s immunization efforts. Health challenges were significant: infant mortality stood at 88 per 1,000 live births, and under-five mortality reached 136 per 1,000.
Most child deaths were linked to preventable conditions: diarrhea accounted for 22%, pneumonia for 21%, neonatal asphyxia for 10%, and malaria for 9%. Economic hardship compounded the challenge—by 2001, over 70% of the population lived below the poverty line, rising to over 80% after the 2002 crisis. These realities made immunization a key health and poverty-reduction intervention.
Expanded Program on Immunization (EPI) Strategy
Madagascar’s EPI began in 1976 with core vaccines for children under two, including diphtheria, tetanus, whooping cough, and tuberculosis. Over time, the program expanded to include tetanus vaccination for pregnant women, polio, measles, hepatitis B, and Hib.
By the early 2000s, the focus shifted toward increasing coverage, introducing new vaccines, and ensuring long-term financial sustainability. Between 1991 and 2001, DTP3 coverage—a key global immunization benchmark—dropped from 59% to 46%, while full immunization rates fell to 36%.
To address these gaps, Madagascar set clear objectives for 2003–2013: reach at least 80% coverage nationwide for all EPI antigens, introduce new vaccines, and focus on disease control efforts such as polio eradication and elimination of maternal and neonatal tetanus.
Vaccine Coverage Progress and Challenges
Improving vaccine coverage involved confronting gaps in routine immunization and operational hurdles. Key challenges included:
- Coverage rate fluctuations: DTP3 coverage fell from 59% (1991) to 46% (2001); full immunization rates dropped to 36%.
- Vaccine wastage (2000–2002): BCG up to 43.3%, measles up to 36.2%, DTP as low as 13.8%.
- Operational challenges: Limited cold chain infrastructure, shortages of trained staff in rural districts, and public knowledge gaps about vaccines.
Strategic solutions implemented included:
- Adoption of auto-disable syringes and safety boxes.
- Cold-chain upgrades and regular inventory assessments.
- National Immunization Days targeting underserved communities.
These initiatives helped Madagascar reduce vaccine loss and improve coverage.
Financial Sustainability and Funding
Running the EPI required careful financial planning. From 2003 to 2013, Madagascar projected $152.78 million USD to support vaccines, staffing, cold chain maintenance, and outreach. About $80.95 million USD (53%) was secured or probable through government budgets and international partner contributions, leaving a funding gap of $72.83 million USD (47%).
Key financial highlights:
- Annual program costs ranged from $2.86 million (2000) to $9.37 million (2002, including polio campaigns).
- Cost per DTP3 vaccinated child peaked at $15.75 USD in 2002.
- Government funding primarily covered staffing and operational costs, while vaccines were largely supported by international partners such as UNICEF, WHO, and USAID.
Madagascar’s approach emphasized gradually increasing domestic contributions while coordinating international support.
Strategic Approach to Program Sustainability
The Ministry of Health chose a balanced strategy to increase vaccination coverage, manage wastage efficiently, and introduce new vaccines without overstretching resources. Core elements included:
- Vaccination coverage goals: 78–92% national coverage for all EPI antigens (2004–2013), prioritizing underserved districts.
- Introduction of Hib vaccine: Countrywide rollout starting in 2006, using DTP-Hib combination and single-dose Hepatitis B vaccines.
- Vaccine wastage reduction: Target of 2% wastage for key antigens by 2013, achieved through staff training and stock management.
- Gradual financial transition: Increasing government funding share while leveraging international support.
Key program investments
- Cold chain development: Aim for 90% national coverage by 2005, full coverage by 2007, with new equipment and staff training.
- Training and workforce expansion: Management and technical training for health workers and supervisors.
- Outreach and social mobilization: Mobile vaccination teams and national communication campaigns to improve coverage in remote areas.
- Waste management and injection safety: Nationwide adoption of auto-disable syringes and proper disposal systems.
Lessons Learned
Madagascar’s experience offers valuable insights:
- Financial planning as a health strategy: Early identification of funding gaps and progressive domestic investment were critical.
- Integration of disease surveillance and routine services: National Immunization Days complemented routine services, boosting coverage.
- Focused partner coordination: Clear roles for international partners avoided overlap and maximized resources.
Conclusion
Madagascar’s Expanded Program on Immunization from 2003 to 2013 demonstrates how strategic planning, financial discipline, and targeted health interventions can improve child health outcomes, even in resource-limited settings. By expanding vaccine coverage, strengthening cold chain infrastructure, and gradually increasing domestic funding, Madagascar built a sustainable foundation for long-term immunization success.
For countries aiming to strengthen their own vaccination programs, Madagascar’s approach provides a practical example of balancing ambition with financial planning to protect children and communities.