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

Date Published: August 20, 2019

Publisher: Public Library of Science

Author(s): Camille Ezran, Matthew H. Bonds, Ann C. Miller, Laura F. Cordier, Justin Haruna, David Mwanawabenea, Marius Randriamanambintsoa, Hery-Tiana R. Razanadrakato, Mohammed Ali Ouenzar, Bénédicte R. Razafinjato, Megan Murray, Andres Garchitorena, Lars Åke Persson

Abstract: BackgroundIn 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 findingsWe 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 assessed. The reported prescription rate for oral rehydration therapy among children with diarrhea changed by +68.5% (from 29.6% to 49.9%) and −23.2% (from 17.8% to 13.7%) in the intervention and non-intervention groups, respectively (p-value = 0.05). However, trends observed in the care content varied widely by indicator and did not always match the large apparent increases observed in care seeking behavior, particularly for antenatal care, reflecting important gaps in the provision of essential health services for individuals who sought care. The main limitation of this study is that the intervention catchment was not randomly allocated, and some demographic indicators were better for this group at baseline than for the rest of the district, which could have impacted the trends observed.ConclusionUsing a district-representative longitudinal cohort to assess the content of care delivered to the population, we found a substantial increase over the two-year study period in the prescription rate for ill children and in all World Health Organization (WHO)-recommended perinatal care outputs assessed in the intervention group, with more modest changes observed in the non-intervention group. Despite improvements associated with the HSS intervention, this study highlights the need for further quality improvement in certain areas of the district’s healthcare system. We show how content of care, measured through standard population-based surveys, can be used as a component of HSS impact evaluations, enabling healthcare leaders to track progress as well as identify and address specific gaps in the provision of services that extend beyond care access.

Partial Text: The advent of the United Nations Sustainable Development Goals (SDGs) in 2015 bolstered a global commitment towards achieving universal health coverage (UHC) for all populations by 2030 through strengthened primary care [1,2]. As the 40th anniversary of the Declaration of Alma-Ata for UHC was recently celebrated [3], an estimated 60% of the world’s population has access to quality essential healthcare services, medicines, and vaccines, as well as financial risk protection [4]. Although achieving UHC for the remaining approximately 3 billion people in the next decade will require substantial investment [5], recent progress in several low- and middle-income countries such as Cambodia and Rwanda suggests that this ambitious goal is within reach [6]. Their gains in health coverage have been attributed in large part to reductions in financial barriers and sustained investments to strengthen the health system across the entire continuum of care [7,8].

The IHOPE study included 1,333 children under five in the 2014 survey and 1,345 children in the 2016 survey (31.0% and 29.7% in the intervention group, respectively). It also included 1,635 women aged 15–49 in the 2014 survey and 1,585 women in the 2016 survey (39.2% and 37.5% in the intervention group, respectively). While many demographic characteristics were similar between the two groups (Table 1), the household wealth index,maternal education level and literacy rate were higher in the intervention group than in the non-intervention group. The nonresponse rate was low (<2%) for all questions of care seeking behavior and care content assessed, with no significant differences between the two groups observed (S2 Table). Of the 15.6 million avertable deaths that occurred in 2016 in low- and middle-income countries, an estimated 3.6 million were attributable to non-utilization of healthcare services, while 5.0 million were attributable to receipt of low-quality care [49]. In this study, we used an open district-representative longitudinal cohort to assess the content of care delivered to the population in the Ifanadiana district as a proxy for estimating the impact of an integrated HSS initiative on healthcare quality. The results revealed that over the two-year study period, care seeking behavior appeared to have substantially increased in the intervention group compared with the non-intervention group for sick-child care (DiD = 23.3%, p-value = 0.01) and perinatal care (DiD = 11.3%, p-value = 0.13), with a more marginal difference observed between the two groups for antenatal care (DiD = 2.0%, p-value = 0.75). Source:


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