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Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar

Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar
Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar

Introduction The Sustainable Development Goals framed an unprecedented commitment to achieve global convergence in child and maternal mortality rates through 2030. To meet those targets, essential health services must be scaled via integration with strengthened health systems. This is especially urgent in Madagascar, the country with the lowest level of financing for health in the world. Here, we present an interim evaluation of the first 2 years of a district-level health system strengthening (HSS) initiative in rural Madagascar, using estimates of intervention coverage and mortality rates from a district-wide longitudinal cohort.

Methods We carried out a district representative household survey at baseline of the HSS intervention in over 1500 households in Ifanadiana district. The first follow-up was after the first 2 years of the initiative. For each survey, we estimated maternal, newborn and child health (MNCH) coverage, healthcare inequalities and child mortality rates both in the initial intervention catchment area and in the rest of the district. We evaluated changes between the two areas through difference-in-differences analyses. We estimated annual changes in health centre per capita utilisation from 2013 to 2016.

Results The intervention was associated with 19.1% and 36.4% decreases in under-five and neonatal mortality, respectively, although these were not statistically significant. The composite coverage index (a summary measure of MNCH coverage) increased by 30.1%, with a notable 63% increase in deliveries in health facilities. Improvements in coverage were substantially larger in the HSS catchment area and led to an overall reduction in healthcare inequalities. Health centre utilisation rates in the catchment tripled for most types of care during the study period.

Conclusion At the earliest stages of an HSS intervention, the rapid improvements observed for Ifanadiana add to preliminary evidence supporting the untapped and poorly understood potential of integrated HSS interventions on population health.

2059-7908
1-12
Garchitorena, Andres
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Miller, Ann C.
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Cordier, Laura F.
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Rabeza, Victor R.
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Randriamanambintsoa, Marius
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Razanadrakato, Hery Tiana R.
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Hall, Lara
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Gikic, Djordje
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Haruna, Justin
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McCarty, Meg
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Randrianambinina, Andriamihaja
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Thomson, Dana R.
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Atwood, Sidney
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Rich, Michael L.
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Murray, Megan B.
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Ratsirarson, Josea
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Ouenzar, Mohammed Ali
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Bonds, Matthew H.
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Garchitorena, Andres
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Miller, Ann C.
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Cordier, Laura F.
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Rabeza, Victor R.
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Randriamanambintsoa, Marius
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Razanadrakato, Hery Tiana R.
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Hall, Lara
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Gikic, Djordje
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Haruna, Justin
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McCarty, Meg
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Randrianambinina, Andriamihaja
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Thomson, Dana R.
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Atwood, Sidney
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Rich, Michael L.
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Murray, Megan B.
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Ratsirarson, Josea
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Ouenzar, Mohammed Ali
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Bonds, Matthew H.
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Garchitorena, Andres, Miller, Ann C., Cordier, Laura F., Rabeza, Victor R., Randriamanambintsoa, Marius, Razanadrakato, Hery Tiana R., Hall, Lara, Gikic, Djordje, Haruna, Justin, McCarty, Meg, Randrianambinina, Andriamihaja, Thomson, Dana R., Atwood, Sidney, Rich, Michael L., Murray, Megan B., Ratsirarson, Josea, Ouenzar, Mohammed Ali and Bonds, Matthew H. (2018) Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar. BMJ Global Health, 3 (3), 1-12, [e000762]. (doi:10.1136/bmjgh-2018-000762).

Record type: Article

Abstract

Introduction The Sustainable Development Goals framed an unprecedented commitment to achieve global convergence in child and maternal mortality rates through 2030. To meet those targets, essential health services must be scaled via integration with strengthened health systems. This is especially urgent in Madagascar, the country with the lowest level of financing for health in the world. Here, we present an interim evaluation of the first 2 years of a district-level health system strengthening (HSS) initiative in rural Madagascar, using estimates of intervention coverage and mortality rates from a district-wide longitudinal cohort.

Methods We carried out a district representative household survey at baseline of the HSS intervention in over 1500 households in Ifanadiana district. The first follow-up was after the first 2 years of the initiative. For each survey, we estimated maternal, newborn and child health (MNCH) coverage, healthcare inequalities and child mortality rates both in the initial intervention catchment area and in the rest of the district. We evaluated changes between the two areas through difference-in-differences analyses. We estimated annual changes in health centre per capita utilisation from 2013 to 2016.

Results The intervention was associated with 19.1% and 36.4% decreases in under-five and neonatal mortality, respectively, although these were not statistically significant. The composite coverage index (a summary measure of MNCH coverage) increased by 30.1%, with a notable 63% increase in deliveries in health facilities. Improvements in coverage were substantially larger in the HSS catchment area and led to an overall reduction in healthcare inequalities. Health centre utilisation rates in the catchment tripled for most types of care during the study period.

Conclusion At the earliest stages of an HSS intervention, the rapid improvements observed for Ifanadiana add to preliminary evidence supporting the untapped and poorly understood potential of integrated HSS interventions on population health.

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Accepted/In Press date: 27 April 2018
e-pub ahead of print date: 4 June 2018
Published date: 1 November 2018

Identifiers

Local EPrints ID: 428761
URI: http://eprints.soton.ac.uk/id/eprint/428761
ISSN: 2059-7908
PURE UUID: 4a2417d0-2dea-4859-8b9f-a777bdc01953
ORCID for Dana R. Thomson: ORCID iD orcid.org/0000-0002-9507-9123

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Date deposited: 08 Mar 2019 17:30
Last modified: 25 Nov 2021 23:12

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Contributors

Author: Andres Garchitorena
Author: Ann C. Miller
Author: Laura F. Cordier
Author: Victor R. Rabeza
Author: Marius Randriamanambintsoa
Author: Hery Tiana R. Razanadrakato
Author: Lara Hall
Author: Djordje Gikic
Author: Justin Haruna
Author: Meg McCarty
Author: Andriamihaja Randrianambinina
Author: Dana R. Thomson ORCID iD
Author: Sidney Atwood
Author: Michael L. Rich
Author: Megan B. Murray
Author: Josea Ratsirarson
Author: Mohammed Ali Ouenzar
Author: Matthew H. Bonds

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