Geographic barriers to achieving universal health coverage: evidence from rural Madagascar

Garchitorena, Andrés; Ihantamalala, Felana Angella; Révillion, Christophe; Cordier, Laura; Randriamihaja, Mauricianot; Razafinjato, Bénédicte; Rafenoarivamalala, Feno H; Finnegan, Karen; Andrianirinarison, Jean Claude; Rakotonirina, Julio; Herbreteau, Vincent; Bonds, Matthew H.

doi:10.1093/heapol/czab087

Cited by 22 publications

(36 citation statements)

References 49 publications

(156 reference statements)

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“…These results suggest that suboptimal testing and treatment of malaria infections in these areas, due to geographic barriers to access health care [ 52 ], could result in undetected pockets of malaria transmission that undermine elimination goals. Indeed, previous studies have shown that persistent geographic inequalities in health care access still exist in rural areas of Madagascar, with an exponential decrease in the use of health facilities over the first 5 km [ 53 ]. Community health programs can be an effective way to remove geographic barriers to health care access [ 54 ], since two community health workers are present in every fokontany independently of their distance to a health facility.…”

Section: Discussionmentioning

confidence: 99%

Identification of factors associated with residual malaria transmission using school-based serological surveys in settings pursuing elimination

Rakotondramanga

Vigan-Womas

Steinhardt

et al. 2022

Malar J

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Background Targeted research on residual malaria transmission is important to improve strategies in settings pursuing elimination, where transmission reductions prove challenging. This study aimed to detect and characterize spatial heterogeneity and factors associated with Plasmodium falciparum infections and exposure, P. falciparum apical membrane antigen 1 (PfAMA1) antibody (Ab) response, in the Central Highlands of Madagascar (CHL). Methods From May to July 2014, a cross-sectional school-based survey was carried out in 182 fokontany (villages) within 7 health districts of the CHL. Rapid diagnostic tests (RDTs) and a bead-based immunoassay including PfAMA1 antigen biomarker were used to estimate malaria prevalence and seroprevalence, respectively. Local Moran’s I index was used to detect spatial “hotspots”. Remotely sensed environmental data—temperature, vegetation indices, land covers, and elevation—were used in multivariable mixed-effects logistic regression models to characterize factors associated with malaria infection and cumulative exposure. Results Among 6,293 school-children ages 2–14 years surveyed, RDT prevalence was low at 0.8% (95% CI 0.6–1.1%), while PfAMA1 Ab seroprevalence was 7.0% (95% CI 6.4–7.7%). Hotspots of PfAMA1 Ab seroprevalence were observed in two districts (Ankazobe and Mandoto). Seroprevalence increased for children living > 5 km from a health centre (adjusted odds ratio (OR) = 1.6, 95% CI 1.2–2.2), and for those experiencing a fever episode in the previous 2 weeks (OR 1.7, 95% CI 1.2–2.4), but decreased at higher elevation (for each 100-m increase, OR = 0.7, 95% CI 0.6–0.8). A clear age pattern was observed whereby children 9–10 years old had an OR of 1.8 (95% CI 1.2–2.4), children 11–12 years an OR of 3.7 (95% CI 2.8–5.0), and children 13–14 years an OR of 5.7 (95% CI 4.0–8.0) for seropositivity, compared with younger children (2–8 years). Conclusion The use of serology in this study provided a better understanding of malaria hotspots and associated factors, revealing a pattern of higher transmission linked to geographical barriers in health care access. The integration of antibody-assays into existing surveillance activities could improve exposure assessment, and may help to monitor the effectiveness of malaria control efforts and adapt elimination interventions.

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Section: Discussionmentioning

confidence: 99%

Identification of factors associated with residual malaria transmission using school-based serological surveys in settings pursuing elimination

Rakotondramanga

Vigan-Womas

Steinhardt

et al. 2022

Malar J

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“…Access to healthcare is a multidimensional metric [75]; however, physical (or geographic) access is consistently described as one of the most critical components of access to healthcare globally [76,77]. The literature shows that lack of physical access remains a dominating factor in decreased utilization of healthcare services which, in turn, propagates negative health outcomes [77][78][79][80][81][82][83][84][85].…”

Section: Health Impactmentioning

confidence: 99%

“…These communities are systematically left out of the majority of health services [87] by the geographic bias of healthcare centers and corresponding transportation networks toward wealthier and more populous urban centers [83,88,89]. Subsequently, in large part due to transportation-based issues, many people in rural and impoverished communities simply go without healthcare services [90], and therefore, face immense health challenges [76,86,91]. However, previous reviews of existing evidence have found positive correlations when investigating the impacts of rural road improvement upon healthcare access in rural communities [8,9].…”

Section: Health Impactmentioning

confidence: 99%

“…Often, publications use distance to describe a lack of access [78,[80][81][82][83][84][85]90,[100][101][102][103][104]. The concept of "distance decay" [76,105] suggests that utilization of healthcare services decreases as the distance required to reach them increases. However, in LMICs, the Euclidean [geometric straight line] distance between a person's place of dwelling and place of healthcare is typically an inaccurate indicator of their ability to access healthcare [84,91,102].…”

Section: Health Impactmentioning

confidence: 99%

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Rural Transportation Infrastructure in Low- and Middle-Income Countries: A Review of Impacts, Implications, and Interventions

Kaiser

Barstow

2022

Sustainability

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The rural transport infrastructure sector is a critical force for sustainable development that is interwoven with many other sectors. Rural transportation is an underlying driver of many of the Sustainable Development Goals (SDGs) and a crucial contributor to many socioeconomic benefits for rural people around the world. This review paper expands upon, enhances, and cross-references the perspectives outlined in previous rural infrastructure-focused review papers. Firstly, this work gives a thorough look into the progress of the rural transportation sector in recent years by focusing on the thematic relationships between infrastructure and other components of sustainable development, namely, economics and agriculture, policy and governance, health, gender, education, and climate change and the environment. Secondly, several strategies, approaches, and tools employed by governments and practitioners within the rural transport sector are analyzed and discussed for their contributions to the wellbeing of rural dwellers in low- and middle-income countries (LMICs). These include rural roads, bridges, maintenance, and non-infrastructural approaches that include concepts such as advanced technological innovations, intermediate modes of transport (IMTs), and transport services. This paper concludes that enhancement, improvement, and extension of rural transportation infrastructure brings significant benefits to rural dwellers. However, this paper also calls for additional integration of the sector and increased usage of systems approaches that view rural transport as an active part of many other sectors and a key leverage point within rural development as a whole. Further, this paper notes areas for future research and investigation, including increased investigation of the relationship between rural transportation infrastructure and education, improved data collection and management in support of improved policymaking, improved prioritization of interventions and institutionalization of maintenance, and expansion of pro-poor transportation strategies and interventions.

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“…An alternative is the use of geographic information from routine health system data. While PHCs typically keep records of a patient's residence to the lowest administrative level (9), this information is not systematically recorded in CHW registries.…”

Section: Introductionmentioning

confidence: 99%

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

Evans

Andréambeloson

Randriamihaja

et al. 2022

Preprint

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Geographic distance is a critical barrier to healthcare access, particularly for rural communities with poor transportation infrastructure who rely on non-motorized transportation. There is broad consensus on the importance of community health workers (CHWs) to reduce the effects of geographic isolation on healthcare access. Due to a lack of fine-scale spatial data and individual patient records, little is known about the precise effects of CHWs on removing geographic barriers at this level of the healthcare system. Relying on a high-quality, crowd-sourced dataset that includes all paths and buildings in the area, we explored the impact of geographic distance from CHWs on the use of CHW services for children under 5 years in the rural district of Ifanadiana, southeastern Madagascar from 2018-2021. We then used this analysis to determine key features of an optimal geographic design of the CHW system, specifically optimizing a single CHW location or installing additional CHW sites. We found that consultation rates by CHWs decreased with increasing distance patients travel to the CHW by approximately 28.1% per km. The optimization exercise revealed that the majority of CHW sites (50/80) were already in an optimal location or shared an optimal location with a primary health clinic. Relocating the remaining CHW sites based on a geographic optimum was predicted to increase consultation rates by only 7.4%. On the other hand, adding a second CHW site was predicted to increase consultation rates by 31.5%, with a larger effect in more geographically dispersed catchments. Geographic distance remains a barrier at the level of the CHW, but optimizing CHW site location based on geography alone will not result in large gains in consultation rates. Rather, alternative strategies, such as the creation of additional CHW sites or proactive care, should be considered.

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Geographic barriers to achieving universal health coverage: evidence from rural Madagascar

Cited by 22 publications

References 49 publications

Identification of factors associated with residual malaria transmission using school-based serological surveys in settings pursuing elimination

Identification of factors associated with residual malaria transmission using school-based serological surveys in settings pursuing elimination

Rural Transportation Infrastructure in Low- and Middle-Income Countries: A Review of Impacts, Implications, and Interventions

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

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