Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar

Abstract

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.

Geographic barriers to care persist at the community healthcare level: evidence from rural Madagascar

“…This effect was greatest in the most dispersed fokontany, and such a solution could be targeted to large, dispersed fokontany where one site cannot adequately serve the whole population (46). Another alternative solution is the creation of proactive community health programs, where CHWs visit all households in their catchment on a regular basis (27,47) Proactive community care programs have been associated with reductions in child mortality rates and increases in access to primary healthcare (47). A pilot proactive community care program is currently being implemented in one commune in Ifanadiana district, with positive initial impacts on consultation rates and quality of care (27).…”

“…Another alternative solution is the creation of proactive community health programs, where CHWs visit all households in their catchment on a regular basis (27,47) Proactive community care programs have been associated with reductions in child mortality rates and increases in access to primary healthcare (47). A pilot proactive community care program is currently being implemented in one commune in Ifanadiana district, with positive initial impacts on consultation rates and quality of care (27). While the limited geographic scale of the program precludes formal statistical analysis, preliminary results show that this program is qualitatively increasing consultation rates in the more dispersed fokontany (Figure S3).…”

“…Ifanadiana is a rural district located in the Vatovavy region in southeastern Madagascar. (27). As of February 2022, this intervention has been implemented in seven communes, equivalent to about half the district, with plans to expand to the entire district by 2023.…”

“…We then explored two potential solutions to geographic barriers for isolated communities in Ifanadiana: optimizing a single CHW site location with regards to distance and installing an additional second site per catchment. (27). As of February 2022, this intervention has been implemented in seven communes, equivalent to about half the district, with plans to expand to the entire district by 2023.…”

“…The national community health policy requires that two volunteer CHWs be locally selected and responsible for each fokontany, the smallest administrative area in Madagascar (mean population of approx. 1200) (27). Fokontany range in size from 1.5 km 2 to 3747 km 2 .…”