Assessing early access to care and child survival during a health system strengthening intervention in Mali: A repeated cross sectional survey

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Study Justification:
– The study aimed to assess the impact of a health system strengthening intervention on early access to care and child survival in Mali.
– The study was conducted because there is a delivery gap between effective methods for child survival and equitable access to those methods.
– The study aimed to measure early child health care access, morbidity, and mortality over the course of the intervention.
Highlights:
– The intervention included Community Health Worker active case finding, user fee removal, infrastructure development, community mobilization, and prevention programming.
– The study conducted four household surveys at baseline and at 12, 24, and 36 months to measure the outcomes.
– The results showed a significant decrease in under-five mortality and prevalence of febrile illness among children under five.
– The percentage of children starting an effective antimalarial within 24 hours of symptom onset also increased significantly.
Recommendations:
– Community-based health systems strengthening interventions may facilitate early access to prevention and care, leading to improved child survival.
– The findings of this study suggest that similar interventions should be implemented in other areas to improve child health outcomes.
Key Role Players:
– Community Health Workers: They play a crucial role in conducting active case finding, diagnosing and treating illnesses, and providing follow-up care.
– Muso: The non-governmental organization that implemented the health system strengthening intervention.
– Malian Ministry of Health: They collaborated with Muso in launching the intervention and provided support for training and infrastructure development.
– Local religious leaders, education centers, and community organizers: They were part of the rapid referral network and helped identify and refer sick children for assessment.
Cost Items for Planning Recommendations:
– Training and employing Community Health Workers
– Removing user fees for healthcare services
– Constructing and renovating clinical infrastructure
– Training healthcare providers
– Microenterprise support for women
– Education programs for community members
– Monitoring and evaluation of the intervention’s impact
Please note that the provided information is a summary of the study and does not include the actual cost estimates.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it presents findings from a repeated cross-sectional survey conducted over a three-year period. The study measured early child health care access, morbidity, and mortality in a health system strengthening intervention in Mali. The results show a statistically significant difference in under-five mortality and improvements in the prevalence of febrile illness and treatment. The study design and methodology are clearly described, and the findings are supported by statistical analysis. To improve the evidence, the abstract could provide more details on the sample size, sampling methodology, and statistical tests used. Additionally, including information on potential limitations of the study would enhance the overall assessment of the evidence.

Background: In 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 Findings: We 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). Conclusions: Community-based health systems strengthening may facilitate early access to prevention and care and may provide a means for improving child survival. © 2013 Johnson et al.

This study was reviewed and approved by the University of California San Francisco Human Research Protection Program Committee on Human Research, IRB #10-02198, Reference #004193. All respondents provided written informed consent. Written informed consent was obtained from the parents/guardians of respondents younger than 18 years of age. The non-governmental organization Muso and the Malian Ministry of Health (MoH) launched their health system strengthening intervention in the periurban area of Yirimadjo in Mali in September 2008. Mali is ranked amongst the world’s poorest countries and has the world’s eighth highest under-five child mortality rate, projected to be 128/1000 live births in 2012 [27]–[28]. Since the Bamako Initiative of 1987 [29], the public sector health system has utilized a user fee for service health care financing model. Approximately 3.5 square miles on the outskirts of Bamako, Yirimadjo has an estimated population of 56,000, and has experienced rapid population growth due to high birth rates and in-migration. At baseline, the public sector health provided primary care through a primary care center that consisted of a consultation room, medicine dispensary, observation room, and two rooms for labor and delivery. Relays, local volunteers, had been trained through the MoH to share key messages with other community members about maternal-child health. At baseline, there were no Community Health Workers providing community-based management of childhood illness. In partnership with local, regional, and national structures of the Malian MoH, Muso undertook a three-component intervention to overcome health system barriers to timely access to preventative and curative care (Table 1). The model is diagrammed in Figure S1. The first component of the intervention involved (i) selecting, training, and employing Community Health Workers to conduct active door-to-door case finding, identifying 16 danger signs and symptoms of childhood illness for children 0–59 months, diagnosing malaria in the home using HRP-2 rapid antigen diagnostic testing, treating malaria in the home with artemisinin-based combination therapy (ACT), referring or accompanying patients with other illnesses to a MoH community health center, conducting follow-up visits for treated patients at 24 and 48 hours, and connecting pregnant women with prenatal care and birthing services (ii) removing user fees to provide free care for all patients who could not afford to pay, as determined by patient self-reporting to their CHW that they were unable to pay (iii) constructing and renovating clinical infrastructure at the MoH community health center and (iv) training of health care providers at the MoH community health center. User fee removal, CHWs, and health center construction were all fully deployed by September 2008. A team of 20 CHWs and 3 CHW assistants provided outreach and care to the 11,000 households in the area of the intervention. Residents of the communities they serve, this new cadre of community-based health professionals were nominated by their communities and selected by a committee that included representatives of the community, the MoH health center, and Muso. The CHWs were jointly trained and supervised by Muso and the MoH health center clinical team. The area of the intervention, estimated population 56,000, was divided into 20 zones, each served by a CHW. Thus each CHW provided outreach and care to a zone with an average population of 2800, of which 560 were children aged 0–59 months. CHW diagnosis and treatment algorithms were built from WHO recommendations for the Integrated Management of Childhood Illness. These CHW protocols (Figure S2 and Figure S3) are included as supporting information. The second component of the intervention involved the creation of a rapid referral network to identify sick children and refer them early for assessment. The rapid referral network included 13 local religious leaders, 14 education centers, and 238 community organizers, as well as the households they engaged through outreach work. Members of this network trained in the importance of early diagnosis and treatment of sick children. They identified patients, particularly children, who were sick and referred them to a CHW for assessment. They also taught their neighbors and family members about the importance of early diagnosis and treatment for children with fever. The third component addressed the socioeconomic determinants of health disparities through microenterprise support, education, and community organizing. A microenterprise program provided training, savings structures, and low-interest and no-interest loans to women to start or expand revenue generating activities. The microenterprise program was designed to increase women’s income. In doing so, the program aimed to increase women’s decision-making power relative to health decisions for themselves and their children, as well as to increase their capacity to spend on health related commodities, such as soap and nutritious foods. Testing these specific hypotheses was beyond the scope of the current study and will be the subject of future research. The non-formal education curriculum, developed and implemented by the organization Tostan, is a human rights-based curriculum offered to adults and adolescents, which trains community members in community-led development, improving living conditions that influence community health. The three-year curriculum includes modules on human rights, problem solving, project management, democracy, health, hygiene, literacy, numeracy and income generation skills. Health skills modules include family planning, prenatal and perinatal health, vaccinations, malaria prevention and care, diarrheal disease prevention and home-based management, and nutrition. Classes met eight hours per week during the three year curriculum. Muso and Tostan together trained 238 Community Organizers to identify and implement community-designed health and development projects. We conducted independent, randomized cross-sectional household surveys at baseline, 12, 24, and 36 months in the area of intervention starting in June 2008. We included households with a woman aged 16 and older. We sampled 400 households in June 2008 (baseline), June 2009 (12 months), June 2010 (24 months), and 1170 households in June 2011 (36 months). We powered the sample to estimate the percentage of under-five children with a fever in the two weeks prior who received an effective antimalarial within 24 hours of symptom onset, in a population of 56,000, with a 95% confidence level, a 5% margin of error, and a conservative 50% response distribution. We utilized a two-stage cluster sampling methodology with probability of selection proportionate to size to achieve a self-weighting sample of households. In the first-stage of sampling, we generated 40 (2008, 2009, 2010) or 65 (2011) random non-overlapping latitude-longitude coordinates with 100 m radial buffers within the intervention area. Using less than six month old satellite imagery, we counted the number of structures within each cluster as a measure of population density. In the second stage of sampling, interviewers selected households by arriving at the center of the cluster, spinning a pen to identify a random direction, and visiting every second household and choosing a pre-determined number of households proportional to the population density in that cluster. Within each household, one respondent, a female aged 16 or over, was randomly selected from all eligible respondents based on a KISH table. The survey was adapted from existing validated tools created by ICF International [30] and Population Services International (PSI) and included questions about household demographics, fever in children under five, and birth histories (10-year birth histories in 2008, and 6-year birth histories in 2009–2011). Interviewers were hired for the sole purpose of survey administration, and were not members of the communities they surveyed. Data on patient encounters were collected through patient encounter forms completed by MoH Primary Health Center staff and CHWs. The number of patient encounters in which user fees were effectively removed was tracked through an electronic database maintained by a data entry professional based at the Primary Health Center. The number of sick patient visits per month was tracked by the Primary Health Center and provided through the Ministry of Health District Health Information Systems office. Program staff submitted forms to track other program output including education center enrollment and microloan repayment rates, which were then verified by program supervisors. To track exposure to Community Health Worker outreach, we added questions to the 2011 household survey regarding whether and how recently each household had been visited by a CHW. We conducted an adequacy evaluation based on a full coverage intervention to measure changes in early access and under-five mortality outcomes in the surveyed area [31]. We calculated under-five mortality rates from all births reported by respondents in the five years prior to the survey. We calculated under-five mortality rates and compared risk of death before age five across surveys with Cox proportional hazards regression using survey year as the explanatory variable. Children still alive and under age five at the time of survey were right censored. We accounted for clustering of observations by sampling area with the shared frailty option and compared the difference in under-five mortality rates across surveys with the 2008 survey as the reference. The proportional hazard criteria were met. We multiply imputed missing age of death, month of birth, and year of birth based on other covariates using the MICE system of chained equations, and analyzed the results in Stata (v.10) using the multiply imputed datasets to preserve the original sample variability including variability due to missing data. We calculated the proportion of children in the household under age five (both biological and non-biological children of respondents) who were reported to be febrile in the prior two weeks and the proportion of febrile children under-five who received an effective antimalarial treatment within 24 hours of symptom onset. We estimated prevalence in SAS (v.9.2) accounting for clustering with the surveyfreq command, and compared estimates with chi-square statistics, reporting prevalence ratios and p-values with 2008 as the reference.

Based on the information provided, some potential innovations to improve access to maternal health could include:

1. Community Health Worker (CHW) active case finding: This involves training and employing CHWs to conduct door-to-door case finding, identify danger signs and symptoms of childhood illness, diagnose and treat malaria, refer patients with other illnesses to a health center, and provide follow-up visits for treated patients.

2. User fee removal: Removing user fees for healthcare services can help ensure that all patients, including pregnant women, have access to necessary care without financial barriers.

3. Infrastructure development: Constructing and renovating clinical infrastructure at health centers can improve the quality and availability of maternal health services.

4. Community mobilization: Engaging local religious leaders, education centers, and community organizers to raise awareness about the importance of early diagnosis and treatment of sick children can help improve access to care.

5. Prevention programming: Implementing prevention programs that focus on areas such as family planning, prenatal and perinatal health, vaccinations, malaria prevention and care, diarrheal disease prevention and home-based management, and nutrition can contribute to better maternal and child health outcomes.

These innovations were part of a health system strengthening intervention in Mali and were found to facilitate early access to prevention and care, leading to improved child survival rates.
AI Innovations Description
The study mentioned is titled “Assessing early access to care and child survival during a health system strengthening intervention in Mali: A repeated cross-sectional survey.” The study aimed to measure early child health care access, morbidity, and mortality over the course of a health system strengthening intervention in Yirimadjo, Mali. The intervention included various components such as Community Health Worker active case finding, user fee removal, infrastructure development, community mobilization, and prevention programming.

The study conducted four household surveys at baseline and at 12, 24, and 36 months using a cluster-based, population-weighted sampling methodology. The outcomes measured were 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.

The results showed a significant difference in under-five mortality between the baseline and intervention period. The hazard of under-five mortality in the intervention area was one-tenth that of the baseline. The prevalence of febrile illness among children under five was significantly lower after three years of the intervention. The percentage of children starting an effective antimalarial within 24 hours of symptom onset was nearly twice that reported at baseline.

The study concluded that community-based health systems strengthening may facilitate early access to prevention and care, leading to improved child survival.

Overall, the recommendation from this study is to implement a comprehensive health system strengthening intervention that includes components such as active case finding, user fee removal, infrastructure development, community mobilization, and prevention programming. This approach can help improve access to maternal health by ensuring timely and equitable access to effective antimalarials and reducing the prevalence of febrile illness among children.
AI Innovations Methodology
Based on the provided description, the study aimed to assess early access to care and child survival during a health system strengthening intervention in Mali. The intervention included various components such as community health worker active case finding, user fee removal, infrastructure development, community mobilization, and prevention programming. The study conducted four household surveys at baseline and at 12, 24, and 36 months to measure early child health care access, morbidity, and mortality.

To improve access to maternal health, here are some potential recommendations:

1. Increase the number of trained community health workers (CHWs): Expand the CHW program to recruit and train more individuals who can provide essential maternal health services, including prenatal care, postnatal care, and family planning.

2. Strengthen referral networks: Establish and strengthen referral networks between CHWs, primary health centers, and hospitals to ensure timely access to emergency obstetric care for pregnant women experiencing complications.

3. Improve infrastructure: Invest in improving the infrastructure of primary health centers and hospitals to provide better facilities for maternal health services, including labor and delivery rooms, postnatal care units, and neonatal intensive care units.

4. Enhance community mobilization and education: Conduct community mobilization activities to raise awareness about the importance of maternal health and encourage women to seek antenatal care, skilled birth attendance, and postnatal care. Provide education on family planning methods and promote their use.

5. Remove financial barriers: Implement policies to remove user fees for maternal health services, ensuring that women can access care without financial constraints.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage of pregnant women receiving antenatal care, the percentage of births attended by skilled health personnel, and the maternal mortality ratio.

2. Baseline data collection: Collect baseline data on the selected indicators before implementing the recommendations. This can be done through surveys, interviews, or existing health information systems.

3. Implement the recommendations: Roll out the recommended interventions, such as increasing the number of CHWs, strengthening referral networks, improving infrastructure, conducting community mobilization activities, and removing financial barriers.

4. Monitoring and data collection: Continuously monitor the implementation of the recommendations and collect data on the selected indicators. This can be done through regular surveys, health facility records, or monitoring systems.

5. Data analysis: Analyze the collected data to assess the impact of the recommendations on the selected indicators. Compare the post-intervention data with the baseline data to determine the changes in access to maternal health services.

6. Interpretation and reporting: Interpret the findings and report the results, highlighting the improvements in access to maternal health services resulting from the implemented recommendations. Provide recommendations for further improvements based on the analysis.

By following this methodology, it would be possible to simulate the impact of the recommendations on improving access to maternal health and assess the effectiveness of the interventions implemented during the health system strengthening intervention in Mali.

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