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

Aurélie Brunie; James MacCarthy; Brian Mulligan; Yvette Ribaira; Andry Rabemanantsoa; Louisette Rahantanirina; Caleb Parker; Emily Keyes

doi:10.9745/GHSP-D-19-00421

Key Findings

Community health workers (CHWs) in 23% of communities are assigned to cover either more than 1,000 people or more than 25 km².
In 58% of communities, CHWs were more than 2 hours away one way from the health facility; in 61% of communities, CHWs were more than 2 hours from their assigned supply point.

Key Implications

Program managers should consider assigning CHWs to the nearest health facility and placing supply facilities closer to decrease travel time.
Policy makers should give latitude to communities and health centers to select and manage a number of volunteers matching local geographic and population characteristics.

ABSTRACT

Background:

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.

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). 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.

Results:

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).

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 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.

Received: December 12, 2019.
Accepted: July 7, 2020.
Published: September 30, 2020.

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-19-00421

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