February 2025 — Madagascar faced significant challenges with low COVID-19 vaccination rates at just 10%, far below the WHO's recommended 60%. Additionally, over 1.2 million children were identified as having zero doses of routine immunizations. Key barriers included widespread rumors, inadequate knowledge of vaccination schedules, long distances to health centers, and perceptions of poor hospitality from health workers.

To address these issues, the Comprehensive Rapid Assessment (CRA) recommended:

• • Integrating COVID-19 vaccination with routine immunization and maternal, newborn, child, and adolescent health (MNCAH) services.

  • Engaging professional associations, religious and traditional leaders, and other key influencers.

  • Utilizing behavioral science approaches to promote immunization as a social norm.

  • Tailoring strategies for specific priority groups such as health workers, elderly people, and pregnant women.

Social and Behavior Change for Action (SBC4A) Strategy

The SBC4A strategy focused on transforming intentions into actions through:

• Behavioral Sciences: Promoting immunization as a social norm.

• Engaging Influencers: Leveraging the influence of religious and traditional leaders, and positive role models.

• Community Engagement: Implementing house-to-house visits, theatrical plays, and media amplification of testimonies.

Action-5 Strategy

A key component of SBC4A, the Action-5 strategy, encouraged each vaccinated individual to motivate five others to get vaccinated, creating a web of influence. This approach significantly increased community engagement and vaccination uptake.

Mid-Term Results

The mid-term results were promising:

• 99% of those exposed to the campaign were willing to get vaccinated.

• 53% reported receiving at least one dose of the COVID-19 vaccine.

• 95% of the exposed population fully vaccinated their children.

• Over 18,000 children were vaccinated in the four implementing regions, directly attributed to SBC4A efforts.

Successes and Areas for Improvement

The initiative saw a sharp increase in the uptake of routine vaccinations and successfully leveraged community gatherings and media to amplify positive experiences. However, there is a need for better planning of household visits and improved documentation of referral systems to track zero-dose children.

Looking Forward

Future efforts will focus on maintaining the momentum of the Action-5 initiative, deploying referral tools, and strengthening partnerships with traditional doctors to trace and influence caregivers of zero-dose children.

The SBC4A strategy in Madagascar is a testament to the power of community engagement and behavioral science in transforming public health outcomes. With continued efforts and strategic improvements, Madagascar is on a promising path to achieving higher vaccination rates and better health for its population.