@article{fdi:010083826,
  title = {{G}eographic barriers to achieving universal health coverage : evidence from rural {M}adagascar},
  author = {{G}architorena, {A}ndres and {I}hantamalala, {F}. {A}. and {R}evillion, {C}. and {C}ordier, {L}. {F}. and {R}andriamihaja, {M}. and {R}azafinjato, {B}. and {R}afenoarivamalala, {F}. {H}. and {F}innegan, {K}. {E}. and {A}ndrianirinarison, {J}. {C}. and {R}akotonirina, {J}. and {H}erbreteau, {V}incent and {B}onds, {M}. {H}.},
  editor = {},
  language = {{ENG}},
  abstract = {{P}oor geographic access can persist even when affordable and well-functioning health systems are in place, limiting efforts for universal health coverage ({UHC}). {I}t is unclear how to balance support for health facilities and community health workers in {UHC} national strategies. {T}he goal of this study was to evaluate how a health system strengthening ({HSS}) intervention aimed towards {UHC} affected the geographic access to primary care in a rural district of {M}adagascar. {F}or this, we collected the fokontany of residence (lowest administrative unit) from nearly 300 000 outpatient consultations occurring in facilities of {I}fanadiana district in 2014-2017 and in the subset of community sites supported by the {HSS} intervention. {D}istance from patients to facilities was accurately estimated following a full mapping of the district's footpaths and residential areas. {W}e modelled per capita utilization for each fokontany through interrupted time-series analyses with control groups, accounting for nonlinear relationships with distance and travel time among other factors, and we predicted facility utilization across the district under a scenario with and without {HSS}. {F}inally, we compared geographic trends in primary care when combining utilization at health facilities and community sites. {W}e find that facility-based interventions similar to those in {UHC} strategies achieved high utilization rates of 1-3 consultations per person year only among populations living in close proximity to facilities. {W}e predict that scaling only facility-based {HSS} programmes would result in large gaps in access, with over 75% of the population unable to reach one consultation per person year. {C}ommunity health delivery, available only for children under 5 years, provided major improvements in service utilization regardless of their distance from facilities, contributing to 90% of primary care consultations in remote populations. {O}ur results reveal the geographic limits of current {UHC} strategies and highlight the need to invest on professionalized community health programmes with larger scopes of service.},
  keywords = {{C}ommunity health ; geographical information systems ; healthcare ; utilization ; health systems research ; inequality ; {MADAGASCAR} ; {IFANADIANA}},
  booktitle = {},
  journal = {{H}ealth {P}olicy and {P}lanning},
  volume = {36},
  numero = {10},
  pages = {1659--1670},
  ISSN = {0268-1080},
  year = {2021},
  DOI = {10.1093/heapol/czab087},
  URL = {https://www.documentation.ird.fr/hor/fdi:010083826},
}