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

Abstract

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.

Impact of health system strengthening on delivery strategies to improve child immunisation coverage and inequalities in rural Madagascar

“…Consistent with previous studies, changes in inequalities were measured as the gap in vaccination coverage between the worst-off quantiles (Q1–Q2) and the best-off quantiles (Q3–Q5) over time. 43 55 56 …”

“… 42 Though the partnership does not include a particular focus on immunisation (which is managed directly by the MoPH), it supports a large range of interventions at health centres and community health sites in approximately one-third of the district, which has resulted in substantial increases in primary healthcare access and utilisation. 43 Those programmes include improved ‘readiness’ of health facilities (staffing, training, equipment, infrastructure, supply chain) and clinical programmes that can directly influence adherence to vaccinations schedules, such as family planning, antenatal care, postnatal care and deliveries at health facilities.…”

Integrating Health Systems and Science to Respond to COVID-19 in a Model District of Rural Madagascar

“…Plans were also made for possible delays in supply chain systems for critical items unrelated to COVID-19, such as malaria rapid diagnostic tests (RDTs) and medications. To reduce transmission by and to health care workers, PPE, including surgical masks, N95 masks, gloves, goggles, disposable gowns and foot-covers, were provided to the district health office, and then distributed to health facilities ( 19 , 21 , 22 ).…”

“…The result has been substantial increases in utilization rates of health facilities and community health, as well-progress in neonatal, infant and under-five mortality, and population-based improvements in the coverage of essential services such as antenatal care, delivery in health facilities, and vaccines. For more details on the MoPH-PIVOT model, history, and impact analyses, see ( 20 , 21 ).…”

Impact of health system strengthening on delivery strategies to improve child immunization coverage and inequalities in rural Madagascar

“…In 2014, the Ministry of Public Health (MoPH) partnered with the nongovernmental healthcare organization, PIVOT, to strengthen the rural health district of Ifanadiana, located in southeastern Madagascar, to improve local health conditions and serve as a model health system for the country [42]. Though the partnership does not include a particular focus on immunization (which is managed directly by the MoPH), it supports a large range of interventions at health centers and community health sites in approximately one third of the district, which has resulted in substantial increases in primary health care access and utilization [43]. Those programs include improved 'readiness' of health facilities (staffing, training, equipment, infrastructure, supply chain) and clinical programs that can directly influence adherence to vaccinations schedules, such as family planning, antenatal care, postnatal care, and deliveries at health facilities.…”