Ezran C., Bonds M. H., Miller A. C., Cordier L. F., Haruna J., Mwanawabenea D., Randriamanambintsoa M., Razanadrakato H. T. R., Ouenzar M. A., Razafinjato B. R., Murray M., Garchitorena Andres. (2019). Assessing trends in the content of maternal and child care following a health system strengthening initiative in rural Madagascar : a longitudinal cohort study. PLoS Medicine, 16 (8), p. e1002869 [23 p.]. ISSN 1549-1277.
Auteurs
Ezran C., Bonds M. H., Miller A. C., Cordier L. F., Haruna J., Mwanawabenea D., Randriamanambintsoa M., Razanadrakato H. T. R., Ouenzar M. A., Razafinjato B. R., Murray M., Garchitorena Andres
Author summary Why was this study done? One of the largest contributors to preventable deaths in low- and middle-income countries is poor quality of care delivered by the public health system. Yet, given the multiple dimensions of care quality, there are currently no standard measures to evaluate impacts in this domain. While health system strengthening (HSS) initiatives strive to simultaneously increase access to healthcare and improve care quality, few studies have evaluated the impact of HSS initiatives on both targets. Our study sought to determine whether an HSS intervention in a rural health district of Madagascar, one of the world's poorest countries, improved the quality of maternal and child care at the population level. What did the researchers do and find? We used data from a district-representative open longitudinal cohort that followed over 1,500 households between 2014 and 2016, in order to compare trends in the content of care as a proxy for care quality, inside and outside the intervention catchment, through difference-in-differences analyses. We also analysed data from a Service Availability and Readiness Assessment (SARA) conducted in health facilities supported by the HSS intervention. Our data set included self-reported information on health seeking behaviors and care content for common illnesses of children under five ( = 657 in 2014; 411 in 2016), and for maternal care before and during live births that occurred in the previous two years ( = 552 in 2014; 524 in 2016). nnWe found that compared to the non-intervention group, the intervention group experienced a larger improvement in most care content outputs for childhood illnesses (e.g., 24.4% more children with diarrhea were prescribed oral rehydration therapy after two years than in the non-intervention area) and for perinatal care, whereas trends in antenatal care content were more similar in both populations. Despite progress, there remained important gaps in the provision of essential health services for individuals in both the intervention and non-intervention groups. What do these findings mean? The study provides evidence that HSS initiatives can successfully increase access to healthcare in target populations while also improving the quality of certain primary care services provided. The approach used here can be adapted to other local HSS initiatives to stimulate more comprehensive impact evaluations. Evidence from this study can help guide investments in integrated primary care systems that are needed globally to improve maternal and child care. The interpretation of the study findings is limited by the absence of randomization in the allocation of the intervention's programs and by the reliance on self-reported answers. Background In 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 findings We 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. Conclusion Using 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.
