Article Text

District-level health system strengthening for universal health coverage: evidence from a longitudinal cohort study in rural Madagascar, 2014-2018
  1. Andres Garchitorena1,2,
  2. Ann C Miller2,3,
  3. Laura F Cordier2,
  4. Marius Randriamanambintsoa4,
  5. Hery-Tiana R Razanadrakato4,
  6. Mauricianot Randriamihaja2,
  7. Benedicte Razafinjato2,
  8. Karen E Finnegan2,3,
  9. Justin Haruna2,
  10. Luc Rakotonirina2,
  11. Germain Rakotozafy5,
  12. Laliarisoa Raharimamonjy5,
  13. Sidney Atwood6,
  14. Megan B Murray3,
  15. Michael Rich3,
  16. Tara Loyd2,
  17. Gaêtan Duval Solofomalala5,
  18. Matthew H Bonds2,3
  1. 1MIVEGEC, Univ. Montpellier, CNRS, IRD, Montpellier, France
  2. 2PIVOT, Ifanadiana, Madagascar
  3. 3Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  4. 4Direction de la Démographie et des Statistiques Sociales, Institut National de la Statistique, Antananarivo, Madagascar
  5. 5Ministère de la Santé Publique, Antananarivo, Madagascar
  6. 6Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Andres Garchitorena; andres.garchitorena{at}


Introduction Despite renewed commitment to universal health coverage and health system strengthening (HSS) to improve access to primary care, there is insufficient evidence to guide their design and implementation. To address this, we conducted an impact evaluation of an ongoing HSS initiative in rural Madagascar, combining data from a longitudinal cohort and primary health centres.

Methods We carried out a district representative household survey at the start of the HSS intervention in 2014 in over 1500 households in Ifanadiana district, and conducted follow-up surveys at 2 and 4 years. At each time point, we estimated maternal, newborn and child health coverage; economic and geographical inequalities in coverage; and child mortality rates; both in the HSS intervention and control catchments. We used logistic regression models to evaluate changes associated with exposure to the HSS intervention. We also estimated changes in health centre per capita utilisation during 2013 to 2018.

Results Child mortality rates decreased faster in the HSS than in the control catchment. We observed significant improvements in care seeking for children under 5 years of age (OR 1.23; 95% CI 1.05 to 1.44) and individuals of all ages (OR 1.37, 95% CI 1.19 to 1.58), but no significant differences in maternal care coverage. Economic inequalities in most coverage indicators were reduced, while geographical inequalities worsened in nearly half of the indicators.

Conclusion The results demonstrate improvements in care seeking and economic inequalities linked to the early stages of a HSS intervention in rural Madagascar. Additional improvements in this context of persistent geographical inequalities will require a stronger focus on community health.

  • health systems
  • child health
  • health services research
  • maternal health
  • cohort study

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  • Handling editor Seye Abimbola

  • Contributors Conceived and designed the experiments: AG, ACM, MB. Performed the analysis: AG, ACM, MauR. Contributed reagents/materials/data/analysis tools: AG, ACM, MarR, H-TRR, BR. Wrote the initial draft of the manuscript: AG, ACM, KEF, MB. Revised the manuscript and accepted it in its final form: AG, ACM, LC, MarR, H-TRR, MauR, BR, KEF, JH, LuR, GR, LaR, SA, MBM, MLR, TL, GDS, MB.

  • Funding This study was funded by the Herrnstein Family Foundation.

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  • Competing interests Some authors are current or former employees of institutions discussed in this article, including the non-governmental organisation PIVOT and the Government of Madagascar. These affiliations are explicitly listed in the article.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon request to the address

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