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

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.