Obstacles to routine immunization in Madagascar: Structural, relational and cultural constraints

•Parents have little knowledge of the role of immunization on vaccine-preventable diseases.•There is confusion about immunizations, their frequency and number, which can lead to reluctance by parents.•The immunization record, which facilitates access to care, is the main reason why parents use childhood vaccines.•Immunization is not a priority, its delay or interruption is not considered serious for the child's health. This article proposes an overview of anthropological studies concerning childhood immunization in Madagascar, where vaccine coverage still remains low. The COVID-19 epidemic has heightened the reticence of populations to be vaccinated in the public health centres of this country. It appears necessary to study the factors which may impact immunization practices and its representations. The principal results of these studies describe immunization from the perspective of parents of children under five years of age. The role that they attribute to a vaccine is essentially that of reinforcing the health of children against illness. There is a misunderstanding of combination vaccines, one vaccine generally being associated with one disease. The findings also show a complex relationship with immunization, injections and the health passport. Finally, uptake of immunization or not is motivated by the structural and local context such as the perceived frailness of the newborn baby, the practice of post-partum confinement, or the lack of knowledge about the vaccine. Lack of understanding of immunization and mistrust of it are signs of a fragile health system. An in-depth analysis of immunization and the impact of COVID-19 on its perception will provide a clearer view of the fragility of the immunization programmes implemented in Madagascar.