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A GIS Model of the Deployment of Community Health Volunteers in Madagascar

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A GIS Model of the Deployment of Community Health Volunteers in Madagascar ORIGINAL ARTICLE Practical Implications of Policy Guidelines: A GIS Model of the Deployment of Community Health Volunteers in Madagascar Aurélie Brunie,a James MacCarthy,b Brian Mulligan,c Yvette Ribaira,c Andry Rabemanantsoa,c Louisette Rahantanirina,c Caleb Parker,b Emily Keyesd Key Findings ABSTRACT n Background: With increasing interest in strengthening community Community health workers (CHWs) in 23% of health programs nationally comes a need for operationalizing communities are assigned to cover either more 2 them in a realistic and achievable way. Limited information is than 1,000 people or more than 25 km . available to help program managers establish appropriate para- n In 58% of communities, CHWs were more than meters for their context. We examined aspects of program imple- 2 hours away one way from the health facility; in mentation related to deployment patterns of community health 61% of communities, CHWs were more than workers, called agents communautaires or ACs, in 2 districts of 2 hours from their assigned supply point. Madagascar. Methods: By analyzing program data and publicly available Key Implications datasets in a geographic information system (GIS), we estimated the population and surface area coverage expected of ACs in n Program managers should consider assigning 445 fokontany (communities). Additional modeling on travel CHWs to the nearest health facility and placing time demands examined 1-way pedestrian travel time for ACs to supply facilities closer to decrease travel time. receive routine support from their assigned health facilities and n from socially marketed supply points under dry season condi- Policy makers should give latitude to tions, as well as the impact on travel time based on ACs being communities and health centers to select and reassigned to other facilities or supply points. manage a number of volunteers matching local Results: With the current distribution, ACs in 90% of fokontany geographic and population characteristics. have a catchment population of 1,000 or fewer people (2020 esti- mates) 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 improve- ments in those figures (7 and 4 percentage points, respectively). Conclusion: 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 sys- tem 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. INTRODUCTION Community health workers (CHWs) have been a vital a component of primary health care since their incep- Health Services Research, FHI 360, Washington, DC, USA. 1 b tion close to 50 years ago. Although there are some Behavioral, Epidemiological and Clinical Sciences, FHI 360, Durham, NC, USA. examples of well-run CHW programs at scale in coun- c Community Capacity for Health Program, JSI Research & Training Institute, Inc., tries such as Brazil, Bangladesh, or Nepal,2,3 challenges Antananarivo, Madagascar. have also been documented in scaling up and maintain- d Reproductive, Maternal, Newborn and Child Health, FHI 360, Durham, NC, USA. ing CHW programs, including poor planning, lack of co- Correspondence to Aurélie Brunie ([email protected]). ordination among actors, donor-driven management, Global Health: Science and Practice 2020 | Volume 8 | Number 3 466 A GIS Model of Community Health Volunteers in Madagascar www.ghspjournal.org siloed training, poor supervision and support, ten- We conducted 2 sets of analyses that are rele- uous linkages with the health system, and lack of vant in the context of Madagascar and suited to recognition of CHWs’ contributions.4–6 Recently, the use of GIS. The first set of analyses pertains to there has been renewed interest in expanding the how many CHWs to deploy relative to population use of CHWs to address shortages and misdistribu- size and to the size of their catchment area. tion of health workers and to enable progress to- Establishing a realistic target population size typi- wards universal health coverage.1,4 This current cally depends on a constellation of factors includ- drive and the accompanying commitment to inte- ing expected workload, frequency of contact grate CHWs into health systems provide an oppor- required, services provided, expected time com- tunity to strengthen the design and performance mitment, and local geography.1 Currently, some of CHW programs.1,4,5 variability exists across countries in how coverage In 2018, the World Health Organization re- ratios are specified, with assignments for example leased evidence-based guidance on optimal health being defined as a number of people or households policy and system support to optimize the perfor- per facility or per village.11 There is not always a mance and impact of CHWs.1 In practice, howev- clear understanding of how different metrics re- er, CHW programs vary substantially and there is late to each other or how they translate in terms no global blueprint to maximize outputs and out- of the geographic area CHWs may need to move 6 comes. For example, some CHWs are paid, others around depending on their assigned tasks. are volunteers, and some programs are special- The second set of analyses examines travel ized, but others are more extensive in the number time demands associated with maintaining func- of tasks CHWs are expected to perform. In addi- tional linkages to the health system. In settings tion, geography, the distance from a health facili- where CHWs are required to travel to health facil- ty, and cultural diversity provide additional layers ities for supervision and logistical support and sup- of uncertainty and contextual variability. Program plies, they can incur additional transport and managers must find the right combination of key – opportunity costs.12 18 Although reducing the program elements to fit their context, including costs for the populations CHWs serve is recognized training, equipment, supplies, supervision, trans- as a significant advantage of CHW programs, costs port, financing, information systems, quality as- surance and improvement, demand generation, borne by the CHWs are not always adequately 7 considered as part of program design, planning, governance, and incentives. One challenge that 13 decision makers often face in ensuring plans and and implementation. A reality check to verify A reality check to expectations are rational and realistic is a lack of that assignment patterns of CHWs to health facilities verify that adequate information on the existing health infra- are rational and travel time demands realistic based assignment structure, population, and geographic area. Some on health facility location, distance, terrain, and patterns of CHWs emerging tools are becoming available to support road system quality is important to ensure that pro- are rational and managers in operationalizing context-specific grams are well-functioning and sustainable. travel time considerations for CHW programs, including the demands realistic CHW coverage and capacity (C3) tool or the METHODS is important for Community Health Planning and Costing Tool.7,8 well-functioning, To date, however, few resources are available to Setting sustainable support program planning and management. The analyses examined the realities that volunteer programs. We used a geographic information system CHWs face in performing their tasks in 2 districts (GIS) to generate evidence on the reality of CHW of Madagascar (Mandritsara in Sofia region and program implementation in Madagascar to help Mananara Nord in Analanjirofo region) supported program managers get a solid understanding of by the United States Agency for International potential practical issues related to current deploy- Development (USAID) Community Capacity for ment patterns for CHWs and support planning and Health Program, locally known as Mahefa Miaraka, management decisions. The published literature implemented by JSI Research & Training Institute, contains few examples of applying GIS to inform Inc. Conducting this activity in Madagascar is timely management of CHW programs. For example, a because, after updating its National Community previous study used spatial data analysis and GIS Health Policy in 2017, the Ministry of Public Health methods to assess the role of geographical factors (MSANP) is currently developing the associated in variation of CHW performance, but another strategic plan.19,20 The main cadre of CHWs in used GIS as a tool in calculating a cost prediction Madagascar consists of volunteers called agents for implementing a CHW program in a specific communautaires (ACs). Available estimates place area.9,10 the number of trained ACs at over 34,000 across the Global Health: Science and Practice 2020 | Volume 8 | Number 3 467 A GIS Model of Community Health Volunteers in Madagascar www.ghspjournal.org country.21 Order 8014-2009 stipulates a coverage commune (administrative collection of fokon- ratio of 1 AC per village. In practice, implementing tany), and fokontany in Madagascar from the partners, in collaboration
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