Assessing trends in the content of maternal and child care following a health system strengthening initiative in rural Madagascar: A longitudinal cohort study

Abstract

Background In order to reach the health-related Sustainable Development Goals (SDGs) by 2030, gains attained in access to primary healthcare must be matched by gains in the quality of services delivered. Despite the broad consensus around the need to address quality, studies on the impact of health system strengthening (HSS) have focused predominantly on measures of healthcare access. Here, we examine changes in the content of maternal and child care as a proxy for healthcare quality, to better evaluate the effectiveness of an HSS intervention in a rural district of Madagascar. The intervention aimed at improving system readiness at all levels of care (community health, primary health centers, district hospital) through facility renovations, staffing, equipment, and training, while removing logistical and financial barriers to medical care (e.g., ambulance network and user-fee exemptions). Methods and findings We carried out a district-representative open longitudinal cohort study, with surveys administered to 1,522 households in the Ifanadiana district of Madagascar at the start of the HSS intervention in 2014, and again to 1,514 households in 2016. We examined changes in healthcare seeking behavior and outputs for sick-child care among children <5 years old, as well as for antenatal care and perinatal care among women aged 15–49. We used a difference-in-differences (DiD) analysis to compare trends between the intervention group (i.e., people living inside the HSS catchment area) and the non-intervention comparison group (i.e., the rest of the district). In addition, we used health facility–based surveys, monitoring service availability and readiness, to assess changes in the operational capacities of facilities supported by the intervention. The cohort study included 657 and 411 children (mean age = 2 years) reported to be ill in the 2014 and 2016 surveys, respectively (27.8% and 23.8% in the intervention group for each survey), as well as 552 and 524 women (mean age = 28 years) reported to have a live birth within the previous two years in the 2014 and 2016 surveys, respectively (31.5% and 29.6% in the intervention group for each survey). Over the two-year study period, the proportion of people who reported seeking care at health facilities experienced a relative change of +51.2% (from 41.4% in 2014 to 62.5% in 2016) and −7.1% (from 30.0% to 27.9%) in the intervention and non-intervention groups, respectively, for sick-child care (DiD p -value = 0.01); +11.4% (from 78.3% to 87.2%), and +10.3% (from 67.3% to 74.2%) for antenatal care ( p -value = 0.75); and +66.2% (from 23.1% to 38.3%) and +28.9% (from 13.9% to 17.9%) for perinatal care ( p -value = 0.13). Most indicators of care content, including rates of medication prescription and diagnostic test administration, appeared to increase more in the intervention compared to in the non-intervention group for the three areas of care we ...

Networks of Care in Rural Madagascar for Achieving Universal Health Coverage in Ifanadiana District

“…12 From 2014 to 2016, care-seeking for childhood illness increased by 51% in PIVOT-supported areas and fell slightly in the rest of the district; attendance at four or more ANC visits increased for all areas of the district. 13 Beginning with a foundation of agreement and an enabling environment (Domain I), the NOC have been established within a health system where the vision is understood, and roles and responsibilities are delineated across levels of care and between NGO and state actors. Second, the NOC have sought to equip each level of the system with appropriate operational standards (Domain II), including the critical infrastructure necessary for service delivery, and the creation of linkages across the continuum of care.…”

“…PIVOT support to clinical programs, with a focus on child health, maternal and reproductive care, and infectious diseases, have resulted in significant improvements in the coverage and quality of care at facilities. 12,13 Specifically, PIVOT has accompanied the MoPH in the improvement of clinical programs such as Integrated Management of Childhood Illness (IMCI) at community-and CSB-level, malnutrition and tuberculosis, particularly through clinical skills building for health-care workers of each cadre and improved readiness, as mentioned above.…”

“…The focus on implementation science has generated rigorous evidence on the impact of health system strengthening interventions. 12,13,15,16 PIVOT therefore also collaborates with a network of researchers to create a broad field-based research agenda for sustainability. 7,17 Two examples demonstrate how the process of learning through monitoring, evaluation and research is contributing to flexibility and extending the reach of the health system in Ifanadiana, as well on prioritizing patientcenteredness:…”

District-level health system strengthening for universal health coverage: evidence from a longitudinal cohort study in rural Madagascar, 2014-2018

“…A range of HSS programmes were initiated in a third of the district, ensuring health system readiness, improving clinical programmes and supporting integrated information systems at all levels of care. The first 2 years showed improved quality and coverage of primary care services, 30 and declines in child mortality rates. 31 The scope of the programmes and geographical footprint are being progressively scaled, and the government of Madagascar has designated Ifanadiana among the districts for piloting the national UHC strategy.…”

Improving geographical accessibility modeling for operational use by local health actors

“…In 2014, the Madagascar's Ministry of Health (MoH) and the nongovernmental organization PIVOT partnered to strengthen the public health system in the rural district of Ifanadiana, with the aim of attaining UHC and set a model for the country. Despite rapid improvements observed in accessibility and health conditions [50,51], initial analyses suggested that health gains were concentrated in close proximity to health centers [51]. Here, we aimed to develop very precise, context-specific estimates of geographic accessibility to care in Ifanadiana district to help with the design and implementation of interventions that improve access for remote populations.…”