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Despite the widespread global adoption of community health (CH) systems, there are evidence gaps in how to best deliver community-based care aligned with global best practice in remote settings where access to health care is limited and community health workers (CHWs) may be the only available providers. PIVOT partnered with the Ministry of Public Health to pilot a new two-pronged approach for care delivery in rural Madagascar: one CHW provided care at a stationary CH site while 2-5 additional CHWs provided care via proactive household visits. The pilot included professionalization of the CHW workforce (i.e. recruitment, training, financial incentive) and twice monthly supervision of CHWs. We evaluated the impact of the CH pilot on utilization and quality of integrated community case management (iCCM) in the first six months of implementation (October 2019-March 2020).We compared utilization and proxy measures of quality of care (defined as adherence to the iCCM protocol for diagnosis, classification of disease severity, treatment) in the intervention commune and five comparison communes, using a quasi-experimental study design and relying on routinely collected programmatic data. Average per capita monthly under-five visits were 0.28 in the intervention commune and 0.22 in the comparison communes. In the intervention commune, 40.0% of visits were completed at the household via proactive care. CHWs completed all steps of the iCCM protocol in 77.8% of observed visits in the intervention commune (vs 49.5% in the comparison communes, p-value=<0.001). A two-pronged approach to CH delivery and professionalization of the CHW workforce increased utilization and demonstrated satisfactory quality of care. National stakeholders and program managers should evaluate program re-design at a local level prior to national or district-wide scale-up.

IntroductionDespite renewed commitment to universal health coverage and health system strengthening (HSS) to improve access to primary care, there is insufficient evidence to guide their design and implementation. To address this, we conducted an impact evaluation of an ongoing HSS initiative in rural Madagascar, combining data from a longitudinal cohort and primary health centres.MethodsWe carried out a district representative household survey at the start of the HSS intervention in 2014 in over 1500 households in Ifanadiana district, and conducted follow-up surveys at 2 and 4 years. At each time point, we estimated maternal, newborn and child health coverage; economic and geographical inequalities in coverage; and child mortality rates; both in the HSS intervention and control catchments. We used logistic regression models to evaluate changes associated with exposure to the HSS intervention. We also estimated changes in health centre per capita utilisation during 2013 to 2018.ResultsChild mortality rates decreased faster in the HSS than in the control catchment. We observed significant improvements in care seeking for children under 5 years of age (OR 1.23; 95% CI 1.05 to 1.44) and individuals of all ages (OR 1.37, 95% CI 1.19 to 1.58), but no significant differences in maternal care coverage. Economic inequalities in most coverage indicators were reduced, while geographical inequalities worsened in nearly half of the indicators.ConclusionThe results demonstrate improvements in care seeking and economic inequalities linked to the early stages of a HSS intervention in rural Madagascar. Additional improvements in this context of persistent geographical inequalities will require a stronger focus on community health.

There are many outstanding questions about how to control the global COVID-19 pandemic. The information void has been especially stark in the World Health Organization Africa Region, which has low per capita reported cases, low testing rates, low access to therapeutic drugs, and has the longest wait for vaccines. As with all disease, the central challenge in responding to COVID-19 is that it requires integrating complex health systems that incorporate prevention, testing, front line health care, and reliable data to inform policies and their implementation within a relevant timeframe. It requires that the population can rely on the health system, and decision-makers can rely on the data. To understand the process and challenges of such an integrated response in an under-resourced rural African setting, we present the COVID-19 strategy in Ifanadiana District, where a partnership between Malagasy Ministry of Public Health (MoPH) and non-governmental organizations integrates prevention, diagnosis, surveillance, and treatment, in the context of a model health system. These efforts touch every level of the health system in the district—community, primary care centers, hospital—including the establishment of the only RT-PCR lab for SARS-CoV-2 testing outside of the capital. Starting in March of 2021, a second wave of COVID-19 occurred in Madagascar, but there remain fewer cases in Ifanadiana than for many other diseases (e.g., malaria). At the Ifanadiana District Hospital, there have been two deaths that are officially attributed to COVID-19. Here, we describe the main components and challenges of this integrated response, the broad epidemiological contours of the epidemic, and how complex data sources can be developed to address many questions of COVID-19 science. Because of data limitations, it still remains unclear how this epidemic will affect rural areas of Madagascar and other developing countries where health system utilization is relatively low and there is limited capacity to diagnose and treat COVID-19 patients. Widespread population based seroprevalence studies are being implemented in Ifanadiana to inform the COVID-19 response strategy as health systems must simultaneously manage perennial and endemic disease threats.