Assessing the impact of scaling up a health systems strengthening initiative in southeastern Madagascar: baseline socio-economic and health conditions in Vatovavy Region, Madagascar

Assessing the impact of scaling up a health systems strengthening initiative in southeastern Madagascar: baseline socio-economic and health conditions in Vatovavy Region, Madagascar | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Assessing the impact of scaling up a health systems strengthening initiative in southeastern Madagascar: baseline socio-economic and health conditions in Vatovavy Region, Madagascar Hobisoa RAZANADRANAIVO, Ann Miller, Luc Rakotonirina, Sarah-Anne Barriault, and 19 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8595498/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted You are reading this latest preprint version Abstract Despite substantial progress over the past twenty-five years, maternal and child mortality remain high in sub-Saharan Africa. Although there is overwhelming evidence that medical interventions can improve individual health outcomes under trial conditions, the evidence of their impacts at the population level, and of how to scale those impacts, has been more elusive. A central challenge lies in integrating effective medical interventions into high-quality, strengthened health systems and scaling those systems sustainably. The goal of this study was to characterize baseline health and socio-economic conditions in Vatovavy region (population ~900,000), Madagascar, ahead of the scale-up of an HSS initiative that has demonstrated effectiveness after ten years at a district level (~200,000 population) We carried out a population-representative household survey between July and September 2023 across the three districts of Vatovavy (Ifanadiana, Mananjary, and Nosy Varika). A total of 4,997 households (24,000 individuals) were selected using a stratified two-stage cluster sampling design. Face-to-face interviews were conducted with all consenting adults to collect information on demographics, socioeconomic conditions, healthcare access, and health outcomes. Mortality rates were estimated using synthetic life table methods, and health care coverage indicators were defined according to standard DHS guidelines. Health care inequalities were estimated by wealth quintile and by geographic accessibility to health facilities. The regional maternal mortality ratio was estimated at 695 deaths per 100,000 live births (95% CI: 576–832), nearly twice the national average, with marked differences across districts. The under-five mortality rate was 101 per 1,000 live births (95% CI: 90–113), also exceeding national levels. Only 26% of children aged 12–23 months were fully vaccinated, and one-third of births took place in health facilities. Ifanadiana district had notably higher health coverage and lower mortality rates than the other districts. Pronounced inequalities were observed across wealth quintiles and geographic accessibility groups, particularly in Nosy Varika district. This baseline survey reveals poor maternal and child health outcomes ahead of the HSS scale-up in Vatovavy, with strong inter-district variability linked to uneven health system support. Results in Ifanadiana underscore the benefits of ongoing HSS efforts, while persistent geographic inequities call for stronger community-based approaches. These findings provide population-level benchmarks for assessing future intervention impacts. Health sciences/Health care/Public health/Population screening Health sciences/Health care/Health policy Full Text Additional Declarations Yes there is potential Competing Interest. Some authors are current or former employees of institutions discussed in this article, including the non-governmental organization Pivot and the Government of Madagascar. These affiliations are explicitly listed in the article. Supplementary Files SupplementaryInformations.pdf Related Manuscript File Cite Share Download PDF Status: Under Review Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8595498","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":581120316,"identity":"867bc6ba-59b4-4b71-a6ad-186e6619cb46","order_by":0,"name":"Hobisoa RAZANADRANAIVO","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYBACAyjN2AAiExgY5ED0gQekaDEGa0kgWgsQJML04gTm0ocff/i5w052e/vZgx8ettmkzw87/BBoi52cbgN2LZZ9aQaGvWeSjeecyUuWSGxLy914O80AqCXZ2OwADoedYTBI4G1jTpzBkGMgkXDmcO7G2QkgLQcSt+HUwv7h4N+2+sQZ/G+MfwC1pBvOTv9AQAuPYTNv2+HEGRI5ZhIJFYcT5KVzCNnCU8ws23bceIbEGzOLhIo0ww3SOQUHEgzw+YV988e3bdWyM/hzjG/+MLCRl5+dvvnDhwo7OVxasBgCVmlAQBUKkG8gRfUoGAWjYBSMBAAAbXJkyIs4iR8AAAAASUVORK5CYII=","orcid":"","institution":"NGO PIVOT","correspondingAuthor":true,"prefix":"","firstName":"Hobisoa","middleName":"","lastName":"RAZANADRANAIVO","suffix":""},{"id":581120317,"identity":"98f25be3-1846-470f-82fc-c30550551940","order_by":1,"name":"Ann Miller","email":"","orcid":"","institution":"Department of Global Health and Social Medicine, Harvard Medical School","correspondingAuthor":false,"prefix":"","firstName":"Ann","middleName":"","lastName":"Miller","suffix":""},{"id":581120318,"identity":"517656e0-91d5-4e00-8744-d53e30bd4181","order_by":2,"name":"Luc Rakotonirina","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Luc","middleName":"","lastName":"Rakotonirina","suffix":""},{"id":581120319,"identity":"e4ee87e7-9380-45b5-a9ee-f2c3d859da6e","order_by":3,"name":"Sarah-Anne Barriault","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Sarah-Anne","middleName":"","lastName":"Barriault","suffix":""},{"id":581120320,"identity":"0a076485-6d34-4211-b351-8d7f8aadff26","order_by":4,"name":"Benedicte Razafinjato","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Benedicte","middleName":"","lastName":"Razafinjato","suffix":""},{"id":581120325,"identity":"59898ff1-5ed2-40f3-a862-baf3fbdb2f7b","order_by":5,"name":"Jacques Kotchofa","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Jacques","middleName":"","lastName":"Kotchofa","suffix":""},{"id":581120326,"identity":"3b5f6611-2a94-4370-ac2f-9361974018ea","order_by":6,"name":"Feno Rafenoarimalala","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Feno","middleName":"","lastName":"Rafenoarimalala","suffix":""},{"id":581120327,"identity":"e46395a2-32fe-461e-b541-11b40fc327e6","order_by":7,"name":"Elinambinina Rajaonarifara","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Elinambinina","middleName":"","lastName":"Rajaonarifara","suffix":""},{"id":581120328,"identity":"3edac1f6-5bbe-4169-a126-1f8f8fc9522e","order_by":8,"name":"Rado Rakotonanahary","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Rado","middleName":"","lastName":"Rakotonanahary","suffix":""},{"id":581120329,"identity":"b5846826-3f42-4f43-9210-64e33ae71ed5","order_by":9,"name":"Felana Ihantamalala","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Felana","middleName":"","lastName":"Ihantamalala","suffix":""},{"id":581120330,"identity":"cf798d9b-09ae-425f-b648-a5864f9c9da1","order_by":10,"name":"Mauricianot Randriamihaja","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Mauricianot","middleName":"","lastName":"Randriamihaja","suffix":""},{"id":581120331,"identity":"e6cf55dd-25ae-47e5-ad20-1a96865b1f1b","order_by":11,"name":"Vero Ramanandraitsiory","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Vero","middleName":"","lastName":"Ramanandraitsiory","suffix":""},{"id":581120332,"identity":"a9851ab5-8564-4fe5-b7f7-798432e131d5","order_by":12,"name":"Estelle Raza-Fanomezanjanahary","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Estelle","middleName":"","lastName":"Raza-Fanomezanjanahary","suffix":""},{"id":581120333,"identity":"a2531835-8ddf-4775-9653-490270a5d140","order_by":13,"name":"Marius Randriamanambintsoa","email":"","orcid":"","institution":"Direction de la Démographie et des Statistiques Sociales, Institut National de la Statistique","correspondingAuthor":false,"prefix":"","firstName":"Marius","middleName":"","lastName":"Randriamanambintsoa","suffix":""},{"id":581120334,"identity":"b280c169-8939-4ae2-b9cc-44db07918eb8","order_by":14,"name":"Samuel Andrianambinina","email":"","orcid":"","institution":"Direction de la Démographie et des Statistiques Sociales, Institut National de la Statistique","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Andrianambinina","suffix":""},{"id":581120335,"identity":"b5661507-4eb4-4028-a1e2-a83b3761869c","order_by":15,"name":"Delphin Ratsimbazafy","email":"","orcid":"","institution":"Ministry of Public Health in Madagascar","correspondingAuthor":false,"prefix":"","firstName":"Delphin","middleName":"","lastName":"Ratsimbazafy","suffix":""},{"id":581120337,"identity":"b97ef18e-ff2d-4414-86dc-174ca61c2f4d","order_by":16,"name":"Lenjary Rasetrarimanga","email":"","orcid":"","institution":"Ministry of Public Health in Madagascar","correspondingAuthor":false,"prefix":"","firstName":"Lenjary","middleName":"","lastName":"Rasetrarimanga","suffix":""},{"id":581120338,"identity":"17598ad8-fac7-41d1-a1d4-65fcb68bde8d","order_by":17,"name":"Voahangy Rajaonah","email":"","orcid":"","institution":"Ministry of Public Health in Madagascar","correspondingAuthor":false,"prefix":"","firstName":"Voahangy","middleName":"","lastName":"Rajaonah","suffix":""},{"id":581120339,"identity":"4de95564-6480-41d6-a92e-a4b42629ba9c","order_by":18,"name":"Diana Ratsiambakaina","email":"","orcid":"","institution":"Ministry of Public Health in Madagascar","correspondingAuthor":false,"prefix":"","firstName":"Diana","middleName":"","lastName":"Ratsiambakaina","suffix":""},{"id":581120340,"identity":"9f2253cc-7eec-431e-ab54-d646b17ba56b","order_by":19,"name":"Laura Cordier","email":"","orcid":"","institution":"NGO PIVOT","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Cordier","suffix":""},{"id":581120343,"identity":"81f5d48f-bc5f-49f5-8126-46657b080057","order_by":20,"name":"Matthew Bonds","email":"","orcid":"","institution":"NGO PIVOT \u0026 Department of Global Health and Social Medicine, Harvard Medical School","correspondingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"","lastName":"Bonds","suffix":""},{"id":581120344,"identity":"c0e8e6b8-a73c-4419-90df-78369b469e17","order_by":21,"name":"Karen Finnegan","email":"","orcid":"https://orcid.org/0000-0001-9007-5417","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Karen","middleName":"","lastName":"Finnegan","suffix":""},{"id":581120345,"identity":"4c3db730-6677-4f9c-9004-7c20a68aac88","order_by":22,"name":"Andres Garchitorena","email":"","orcid":"","institution":"NGO PIVOT \u0026 MIVEGEC, Univ.Montpellier, CNRS, IRD, Montpellier, France","correspondingAuthor":false,"prefix":"","firstName":"Andres","middleName":"","lastName":"Garchitorena","suffix":""}],"badges":[],"createdAt":"2026-01-13 20:26:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8595498/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8595498/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101297903,"identity":"b076c02f-9d75-4163-ab44-0e7a5f5673ed","added_by":"auto","created_at":"2026-01-28 09:29:15","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1000291,"visible":true,"origin":"","legend":"","description":"","filename":"Mainmanuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8595498/v1_covered_5aa0647d-7743-4d44-9af1-dd4c3289f12e.pdf"},{"id":101292758,"identity":"dc649fdf-0997-4f97-ab81-715dcbbf0ab7","added_by":"auto","created_at":"2026-01-28 08:33:40","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":484203,"visible":true,"origin":"","legend":"Related Manuscript File","description":"","filename":"SupplementaryInformations.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8595498/v1/6689d824508849941f9d8059.pdf"}],"financialInterests":"\u003cb\u003eYes\u003c/b\u003e there is potential Competing Interest.\nSome authors are current or former employees of institutions discussed in this article, including the non-governmental organization Pivot and the Government of Madagascar. These affiliations are explicitly listed in the article.","formattedTitle":"Assessing the impact of scaling up a health systems strengthening initiative in southeastern Madagascar: baseline socio-economic and health conditions in Vatovavy Region, Madagascar","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"nature-portfolio","isNatureJournal":true,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Nature Portfolio","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"ejp","reportingPortfolio":"","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8595498/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8595498/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Despite substantial progress over the past twenty-five years, maternal and child mortality remain high in sub-Saharan Africa. Although there is overwhelming evidence that medical interventions can improve individual health outcomes under trial conditions, the evidence of their impacts at the population level, and of how to scale those impacts, has been more elusive. A central challenge lies in integrating effective medical interventions into high-quality, strengthened health systems and scaling those systems sustainably. The goal of this study was to characterize baseline health and socio-economic conditions in Vatovavy region (population ~900,000), Madagascar, ahead of the scale-up of an HSS initiative that has demonstrated effectiveness after ten years at a district level (~200,000 population) \r\nWe carried out a population-representative household survey between July and September 2023 across the three districts of Vatovavy (Ifanadiana, Mananjary, and Nosy Varika). A total of 4,997 households (24,000 individuals) were selected using a stratified two-stage cluster sampling design. Face-to-face interviews were conducted with all consenting adults to collect information on demographics, socioeconomic conditions, healthcare access, and health outcomes. Mortality rates were estimated using synthetic life table methods, and health care coverage indicators were defined according to standard DHS guidelines. Health care inequalities were estimated by wealth quintile and by geographic accessibility to health facilities.\r\nThe regional maternal mortality ratio was estimated at 695 deaths per 100,000 live births (95% CI: 576–832), nearly twice the national average, with marked differences across districts. The under-five mortality rate was 101 per 1,000 live births (95% CI: 90–113), also exceeding national levels. Only 26% of children aged 12–23 months were fully vaccinated, and one-third of births took place in health facilities. Ifanadiana district had notably higher health coverage and lower mortality rates than the other districts. Pronounced inequalities were observed across wealth quintiles and geographic accessibility groups, particularly in Nosy Varika district.\r\nThis baseline survey reveals poor maternal and child health outcomes ahead of the HSS scale-up in Vatovavy, with strong inter-district variability linked to uneven health system support. Results in Ifanadiana underscore the benefits of ongoing HSS efforts, while persistent geographic inequities call for stronger community-based approaches. These findings provide population-level benchmarks for assessing future intervention impacts.","manuscriptTitle":"Assessing the impact of scaling up a health systems strengthening initiative in southeastern Madagascar: baseline socio-economic and health conditions in Vatovavy Region, Madagascar","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 08:33:30","doi":"10.21203/rs.3.rs-8595498/v1","editorialEvents":[],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"nature-health","isNatureJournal":true,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"nathealth","sideBox":"Learn more about [Nature Health](https://www.nature.com/naturehealth/)","snPcode":"44360","submissionUrl":"https://mts-nathealth.nature.com","title":"Nature Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"cae8b0f4-c94c-4941-a1c5-97a83e0e28ed","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":61819463,"name":"Health sciences/Health care/Public health/Population screening"},{"id":61819464,"name":"Health sciences/Health care/Health policy"}],"tags":[],"updatedAt":"2026-01-28T08:33:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-28 08:33:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8595498","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8595498","identity":"rs-8595498","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}