Abstract
BackgroundIn 2012, 6.6 million children under age five died worldwide, most from diseases with known means of prevention and treatment. A delivery gap persists between well-validated methods for child survival and equitable, timely access to those methods. We measured early child health care access, morbidity, and mortality over the course of a health system strengthening model intervention in Yirimadjo, Mali. The intervention included Community Health Worker active case finding, user fee removal, infrastructure development, community mobilization, and prevention programming.Methods and FindingsWe conducted four household surveys using a cluster-based, population-weighted sampling methodology at baseline and at 12, 24, and 36 months. We defined our outcomes as the percentage of children initiating an effective antimalarial within 24 hours of symptom onset, the percentage of children reported to be febrile within the previous two weeks, and the under-five child mortality rate. We compared prevalence of febrile illness and treatment using chi-square statistics, and estimated and compared under-five mortality rates using Cox proportional hazard regression. There was a statistically significant difference in under-five mortality between the 2008 and 2011 surveys; in 2011, the hazard of under-five mortality in the intervention area was one tenth that of baseline (HR 0.10, p<0.0001). After three years of the intervention, the prevalence of febrile illness among children under five was significantly lower, from 38.2% at baseline to 23.3% in 2011 (PR = 0.61, p = 0.0009). The percentage of children starting an effective antimalarial within 24 hours of symptom onset was nearly twice that reported at baseline (PR = 1.89, p = 0.0195).ConclusionsCommunity-based health systems strengthening may facilitate early access to prevention and care and may provide a means for improving child survival.
Highlights
Despite substantial progress in reducing global child mortality over the past two decades [1], only 13 of 61 countries with high under-five mortality rates are currently on track to meet the fourth Millennium Development Goal: A 2/3 reduction in under-five child mortality by 2015 [2,3,4]
[8] To address these disparities and accelerate progress on child survival, the Global Fund, the World Health Organization (WHO), the GAVI Alliance, the U.S Global Health Initiative, and the World Bank have recently made health system strengthening a key priority for improving child survival and access to health care [9,10]
Of those who had been visited by a Community Health Worker (CHW), 60% reported a visit within the past month, 78% reported a visit within the past three months (Tables S1 and S2)
Summary
Despite substantial progress in reducing global child mortality over the past two decades [1], only 13 of 61 countries with high under-five mortality rates are currently on track to meet the fourth Millennium Development Goal: A 2/3 reduction in under-five child mortality by 2015 [2,3,4]. The leading contributors to child death in resource-limited settings are diarrheal disease, pneumonia, malaria, and neonatal illness [5], all diseases with wellvalidated and low-cost prevention methods and treatments [6,7]. These interventions are not reaching those who most need them [8] To address these disparities and accelerate progress on child survival, the Global Fund, the World Health Organization (WHO), the GAVI Alliance, the U.S Global Health Initiative, and the World Bank have recently made health system strengthening a key priority for improving child survival and access to health care [9,10]. The intervention included Community Health Worker active case finding, user fee removal, infrastructure development, community mobilization, and prevention programming
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