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According to Randriantsimaniry, it was vaccine shortages, especially in remote areas, that led to the measles outbreak this year. During his presidency, Madagascar had very high levels of corruption, Melly said. “Because the regime was undemocratic and unconstitutional, foreign donors mostly stopped approving new aid credits while the US suspended Malagasy exports' preferential access to the American market—a move that had a severe impact on the island's textile industry. Madagascar's Health Sector Development Plan reported a combined state budget in 2015–19 of $200 million per year and only 8–9% of the gross domestic product of Madagascar goes to health, which is far from the commitment of the Abuja Declaration to devote 15% of national budgets to the health sector, says Randriantsimaniry. “Since 2008, the national budget allocated to the sector has followed an irregular trend, with a 70% decrease between 2009 and 2014”, he says.