Malagasy-Led Study Advances Innovative Methods For Understanding Geographic Access To Health Care

Members of the PIVOT team trek to the village of Ambalapaiso, which is located 13 kilometers from the nearest health facility.

 

With more than three and a half billion people lacking access to essential health services, most countries around the globe, including Madagascar, have renewed their commitment to Universal Health Coverage (UHC).

One of the most challenging barriers to achieving UHC in Madagascar is geography, where 60% of the population lives more than 5 kilometers from the nearest health facility. Surprisingly, however, the geography of health access remains poorly understood. Health systems, facility locations, and community health programs are designed with limited understanding of the real geographic barriers to care. Climate, waterways, land use, terrain, and physical distance are all central to determining whether a sick child receives care or a pregnant woman delivers at a facility.

So how can we update modern analytics to break down geographic barriers to care?

A new study led by PIVOT researcher Dr. Felana Ihantamala, also a postdoctoral fellow at Harvard Medical School, has achieved a very precise understanding of local geographic accessibility to health care in Ifanadiana District, Madagascar. The study includes establishing estimates of distance to care for every single household in the area in order to support the programs that deliver health care to remote populations. Beyond improving the precision of previous methods for assessing geographical accessibility, the study has made all the results available for operational use in the field by PIVOT staff and other local health actors in the region via interactive e-health tools.

Recently published in the International Journal of Health Geographics, the study provides a comprehensive picture of the geographic challenges faced by the population to reach the health services they need, be it from the nearest health center or community health worker.

(You can access the full study HERE.)

Dr. Ihantamalala, a health geographer by training, recognizes that, “to optimize local interventions, a very precise understanding of the local geography is necessary to identify populations with poor geographic accessibility to health facilities, to plan field missions, or set up itineraries for community health workers that are doing proactive care, and outreach teams involved in [mobile] vaccination campaigns.”

(Learn more about Felana in her spotlight profile, HERE.)

However, implementation efforts are currently limited by a lack of basic geographic information (e.g. footpaths, residential areas, households) in most rural areas of Madagascar. To solve this in Ifanadiana District, PIVOT partnered with the Humanitarian OpenStreetMap Team and Institut de Recherche pour le Developpement to complete a participatory mapping exercise that ultimately identified more than 100,000 buildings, 5,000 residential areas, 13,000 hectares of rice paddies, and a network of nearly 15,000 miles of footpaths.

Through remote sensing work and GPS measurements, our team is now able to generate accurate estimates of travel time between virtually any two points in the district. To facilitate the operational use of the results of this research by healthcare providers and programmatic teams, the research team developed a web application that is available on PIVOT’s new research dashboard. Beyond this, field workers can also generate accurate directions to any point in Ifanadiana District without internet access (which is scarce throughout the region) using the free “OSMAnd” app on smartphones and tablets.

(Check out the dashboard for yourself, HERE.)

Besides its scientific relevance, this study has contributed to local research capacity-building. PIVOT Associate Scientific Director and senior author of the article, Dr. Andrés Garchitorena, adds that “this work was possible thanks to the contribution of three Malagasy master’s students in GIS and remote sensing who did their thesis on this project, and to several ‘mapathons’ organized at the University of Fianarantsoa and with members of the OpenStreetMap community.”

We know that this type of locally-led scientific approach to solve context-specific barriers to health care can be key tools for achieving UHC in rural areas of the developing world, and look forward to the direct impact that this study will have on PIVOT’s program design and outcomes.




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    • Molecular Diagnostics

      Pivot has partnered with the Ministry of Public Health and Centre ValBio to develop the first molecular diagnostics laboratory for COVID-19 outside of the capital city.  We additionally have partnered with the Pasteur Institute of Madagascar on novel analysis of dried blood spots from I-HOPE survey for serological analysis of measles, malaria, schistosomiasis, Hep B, and COVID-19.

       

      Learn more: 

      Integrating Health Systems and Science to Respond to COVID-19 in a Model District of Madagascar, Rakotonanahary, R.J.L., et al., 2021, Frontiers in Public Health

      Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

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      Learn more:

      Estimating the local spatio‐temporal distribution of malaria from routine health information systems in areas of low health care access and reporting, Hyde, E, et al., 2021, International Journal of Health Geographics

      Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

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      • True representative sample
      • Sample from inside and outside of the initial catchment population
      • Collection by third party professionals at the National Institute of Statistics who collect identical data nationally
      • Tracks same individuals over time
      • Includes biomarkers such as dried blood spots used for molecular analyses

       

      Learn more: 

      Baseline Population Health Conditions Ahead of a Health System Strengthening Program in Rural Madagascar, Miller, A., et al. 2017, Global Health Action

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      Learn more: 

      Integrating Health Systems and Science to Respond to COVID-19 in a Model District of Madagascar, Rakotonanahary, R.J.L., et al., 2021, Frontiers in Public Health

      Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

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      Learn more:

      Estimating the local spatio‐temporal distribution of malaria from routine health information systems in areas of low health care access and reporting, Hyde, E, et al., 2021, International Journal of Health Geographics

      Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

      Towards elimination of lymphatic filariasis in southeastern Madagascar: Successes and challenges for interrupting transmission, Garchitorena, A., et al., 2018, PLOS Neglected Tropical Diseases

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      Learn more:

      Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar, Razafinjato, B., et al., 2020, medRxiv

      Rapid response to a measles outbreak in Ifanadiana District, Madagascar, Finnegan, K.E., et al., 2020 medRxiv

      Networks of Care in Rural Madagascar for Achieving Universal Health Coverage in Ifanadiana District, Cordier, L.F., 2020, Health Systems & Reform

      In Madagascar, Use Of Health Care Services Increased When Fees Were Removed: Lessons For Universal Health Coverage, Garchitorena, A., et al., 2017, Health Affairs

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      Learn more:

      Estimating the local spatio‐temporal distribution of malaria from routine health information systems in areas of low health care access and reporting, Hyde, E, et al., 2021, International Journal of Health Geographics

      Improving geographical accessibility modeling for operational use by local health actors, Ihantamalala, F.A, et al., 2020, International Journal of Health Geographics

      Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar, Razafinjato, B., et al., 2020, medRxiv

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      Learn more:

      District-level health system strengthening for universal health coverage: evidence from a longitudinal cohort study in rural Madagascar, 2014-2018, Garchitorena, A., et al. 2020, BMJ Global Health

      Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar, Garchitorena, A., et al. 2018, BMJ Global Health

      Assessing trends in the content of maternal and child care following a health system strengthening initiative in rural Madagascar: A longitudinal cohort study, Ezran, C., et al. 2019, PLOS Medicine

      Baseline Population Health Conditions Ahead of a Health System Strengthening Program in Rural Madagascar, Miller, A., et al. 2017, Global Health Action

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      A public health system needs dignified and durable spaces – a difficult task in a mountainous rainforest environment. The district’s most remote facilities are a priority, where partnership with local communities and contractors ensure that rehabilitated spaces are maintained over time.

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      TB is so prevalent in Madagascar that there are an estimated 500 new cases in our district every year, most undetected and untreated. In partnership with the National Tuberculosis Program,  we launched a program to control TB in 2017 to upgrade basic resources and capacity, and to ensure that diagnosis and treatment are available in Ifanadiana District.

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      Children under 5 are those most likely to die from preventable causes like malaria, pneumonia and diarrhea. We implement protocols for the Integrated Management of Childhood Illness to guide health workers in diagnosis and treatment and to assess nutrition and vaccine status in low-resource settings.