Practical Implications of Policy Guidelines: A GIS Model of the Deployment of Community Health Volunteers in Madagascar.

Aurélie Brunie,James Maccarthy,Louisette Rahantanirina,Caleb Parker,Yvette Ribaira,Andry Rabemanantsoa,Brian Mulligan,Emily Keyes

doi:10.9745/ghsp-d-19-00421

Aurélie Brunie, James Maccarthy + Show 6 more

Open Access

https://doi.org/10.9745/ghsp-d-19-00421

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Abstract

With increasing interest in strengthening community health programs nationally comes a need for operationalizing them in a realistic and achievable way. Limited information is available to help program managers establish appropriate parameters for their context. We examined aspects of program implementation related to deployment patterns of community health workers, called agents communautaires or ACs, in 2 districts of Madagascar. By analyzing program data and publicly available datasets in a geographic information system (GIS), we estimated the population and surface area coverage expected of ACs in 445 fokontany (communities). Additional modeling on travel time demands examined 1-way pedestrian travel time for ACs to receive routine support from their assigned health facilities and from socially marketed supply points under dry season conditions, as well as the impact on travel time based on ACs being reassigned to other facilities or supply points. With the current distribution, ACs in 90% of fokontany have a catchment population of 1,000 or fewer people (2020 estimates) and ACs in 84% of fokontany have a catchment area of 25 km2 or less. We estimated that ACs in 58% of fokontany were located more than 2 hours from their supporting health facility, and the proportion of fokontany with ACs more than 2 hours away from their assigned supply point was 61%. Reassigning ACs to the closest facility or supply point led to modest improvements in those figures (7 and 4 percentage points, respectively). Findings allow visualizing the practical implications of coverage ratios for ACs to assess whether current demands are realistic. The physical access between ACs and the health system warrants significant attention due to challenges in transport and logistics. Analyses are timely to inform the Ministry of Public Health's strategic thinking in the context of the development of the National Strategic Plan on Strengthening Community Health.

Highlights

Community health workers (CHWs) have been a vital component of primary health care since their inception close to 50 years ago.[1]
962 agents communautaires (AC) were deployed across 445 differ- Overall, 962 ACs ent fokontany and supported by a network of were deployed 56 centres de santé de base (CSB) and 47 points d’approvisionnement (PA)
CSB heads have discretion to add volunteers in situations in which it is warranted by specific local challenges, we found that the current deployment of ACs across the 445 fokontany in the 2 districts largely aligned with the guideline in use of 2 ACs per fokontany that is supported by implementing partners

Summary

Introduction

Community health workers (CHWs) have been a vital component of primary health care since their inception close to 50 years ago.[1]. Program managers must find the right combination of key program elements to fit their context, including training, equipment, supplies, supervision, transport, financing, information systems, quality assurance and improvement, demand generation, governance, and incentives.[7] One challenge that decision makers often face in ensuring plans and expectations are rational and realistic is a lack of adequate information on the existing health infrastructure, population, and geographic area. Methods: By analyzing program data and publicly available datasets in a geographic information system (GIS), we estimated the population and surface area coverage expected of ACs in 445 fokontany (communities).

Results

Discussion

Conclusion