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Randomized Controlled Trial
. 2024 Jun 10;22(1):231.
doi: 10.1186/s12916-024-03441-9.

Expanding community case management of malaria to all ages can improve universal access to malaria diagnosis and treatment: results from a cluster randomized trial in Madagascar

Andres Garchitorena  1   2 , Aina Harimanana  3 , Judickaelle Irinantenaina  3 , Hobisoa Léa Razanadranaivo  3 , Tsinjo Fehizoro Rasoanaivo  3 , Dean Sayre  4 , Julie R Gutman  5 , Reziky Tiandraza Mangahasimbola  3 , Masiarivony Ravaoarimanga  3 , Oméga Raobela  6 , Lala Yvette Razafimaharo  6 , Nicolas Ralemary  7 , Mahefa Andrianasolomanana  8 , Julie Pontarollo  9 , Aline Mukerabirori  10 , Walter Ochieng  11 , Catherine M Dentinger  12 , Laurent Kapesa  13 , Laura C Steinhardt  5
Affiliations
Randomized Controlled Trial

Expanding community case management of malaria to all ages can improve universal access to malaria diagnosis and treatment: results from a cluster randomized trial in Madagascar

Andres Garchitorena et al. BMC Med. .

Abstract

Background: Global progress on malaria control has stalled recently, partly due to challenges in universal access to malaria diagnosis and treatment. Community health workers (CHWs) can play a key role in improving access to malaria care for children under 5 years (CU5), but national policies rarely permit them to treat older individuals. We conducted a two-arm cluster randomized trial in rural Madagascar to assess the impact of expanding malaria community case management (mCCM) to all ages on health care access and use.

Methods: Thirty health centers and their associated CHWs in Farafangana District were randomized 1:1 to mCCM for all ages (intervention) or mCCM for CU5 only (control). Both arms were supported with CHW trainings on malaria case management, community sensitization on free malaria care, monthly supervision of CHWs, and reinforcement of the malaria supply chain. Cross-sectional household surveys in approximately 1600 households were conducted at baseline (Nov-Dec 2019) and endline (Nov-Dec 2021). Monthly data were collected from health center and CHW registers for 36 months (2019-2021). Intervention impact was assessed via difference-in-differences analyses for survey data and interrupted time-series analyses for health system data.

Results: Rates of care-seeking for fever and malaria diagnosis nearly tripled in both arms (from less than 25% to over 60%), driven mostly by increases in CHW care. Age-expanded mCCM yielded additional improvements for individuals over 5 years in the intervention arm (rate ratio for RDTs done in 6-13-year-olds, RRRDT6-13 years = 1.65; 95% CIs 1.45-1.87), but increases were significant only in health system data analyses. Age-expanded mCCM was associated with larger increases for populations living further from health centers (RRRDT6-13 years = 1.21 per km; 95% CIs 1.19-1.23).

Conclusions: Expanding mCCM to all ages can improve universal access to malaria diagnosis and treatment. In addition, strengthening supply chain systems can achieve significant improvements even in the absence of age-expanded mCCM.

Trial registration: The trial was registered at the Pan-African Clinical Trials Registry (#PACTR202001907367187).

Keywords: Community health; Geographic access to care; Health systems strengthening; Last mile interventions; Supply chain.

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Conflict of interest statement

The authors declare that they have no known competing interests that could have appeared to influence the work reported in this paper.

Figures

Fig. 1
Fig. 1
Study design of mCCM cluster randomized trial in Farafangana District. A Map of Farafangana district and the health center catchments randomized to the intervention (yellow) and control arms (green). B Summary diagram of data collected at baseline, follow-up, and endline, and main intervention activities implemented. Note: in addition to household surveys, qualitative information was gathered at endline via individual interviews and focus groups (results presented in a separate manuscript)
Fig. 2
Fig. 2
Average changes in key malaria indicators before and after mCCM implementation in each study arm. A Results from household surveys, estimated among all individuals who reported a fever (for care-seeking and RDT diagnosis) or an RDT+ (for ACT) in the 2 weeks prior to the survey. B Results from health system information, estimated from monthly primary care consultations at health centers and CHWs among the total population in the study area. Results for both levels of care (top panels) in both analyses (survey, health system) represent the sum of percentages or rates from each level of care (health center and CHW level)
Fig. 3
Fig. 3
Changes in rates of malaria diagnosis (RDTs) by age group before and after mCCM implementation in each study arm. A Results from household surveys, comprising individuals who reported a fever in the 2 weeks prior to the survey. B Results from health system information, comprising monthly primary care consultations at health centers and CHWs. Dotted vertical line indicates the beginning of HSS support and age-expanded mCCM. Equivalent figures for fever care-seeking and malaria treatments are available in the Additional file 1
Fig. 4
Fig. 4
Changes in rates of malaria diagnosis (RDTs) by population distance to health centers before and after mCCM implementation in each study arm. A Results from household surveys, comprising individuals who declared being ill in the previous 2 weeks and reported travel time to the nearest health center. B Results from health system information, comprising monthly primary care consultations at health centers and CHWs and estimated distance to the nearest health center via OSRM. Each dot represents the average of one fokontany, with solid lines representing the fitted smooth from a general additive model and its 95% confidence intervals (gray area). Note that y-axis scales are different. Equivalent figures for fever care-seeking and malaria treatments are available in the Additional file 1
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