Figure 1
Cyclone Batsirai passed directly through the Ifanadiana District (Vatovavy Region), Madagascar on February 5, 2022, causing destruction of vital health and transportation infrastructure.
The map illustrates the path of the center of Cyclone Batsirai through Ifanadiana District (inset shows the path in relation to Madagascar). The location of sites in the photos is identified via letters on the map, with a slight offset to reduce overlap. Shading represents historic‑HSSi (beginning pre‑July 2021) and recent‑HSSi zones (beginning post‑July 2021) in the district of Ifanadiana.
Table 1
Summary of HSSi implemented in the Ifanadiana district beginning pre‑July 2021 (historic‑HSSi) and post‑July 2021 (recent‑HSSi) by the WHO HSS component. Reproduced from Garchitorena et al. [15]
| DISTRICT HOSPITAL (CHRD) | PRIMARY CARE FACILITY (CSB2) | COMMUNITY HEALTH1 | |
|---|---|---|---|
| Service delivery | Network of three ambulances for referrals and emergency care; infrastructure renovations, provision of medical and non‑medical equipment, including full laboratory capacity; social support for vulnerable patients | Infrastructure renovations, provision of medical and non‑medical equipment; implementation of IMCI & malnutrition protocols for every child under 5, support for maternal health services | Construction of community health posts by the community, with Pivot support; implementation of IMCI & malnutrition protocols for every child under 5 |
| Health workforce | Staffing of health workers and non‑clinical staff above MoPH norms; trainings for medical staff | Staffing of CSBs above MoPH norms; frequent trainings for medical staff | Training, coaching, and monthly supervision of community health workers by mobile teams of trained nurses and midwives |
| Health information systems | Creation of a hospital‑based M&E team to follow up progress of activities; frequent facility readiness surveys | Joint MoPH‑Pivot training and supervision to improve HMIS data quality | Joint MoPH‑Pivot training to improve HMIS data quality; support for the use of electronic tools for data collection and decision‑making |
| Medicines and supplies | Supply chain management to reduce stock‑outs, management of hospital pharmacy | Supply chain management, training, and reduction of stock‑outs | Monthly provision of MNCH medicine stocks to CHWs and follow‑up of medicine stock use |
| Financing | Cost of outpatient and inpatient care fully covered for referred patients (district hospital and tertiary care outside Ifanadiana) | Essential medicines and consumables provided free of charge to all patients | Cost of MNCH medicine stocks fully covered by Pivot; financial incentives to CHWs for stock management and attendance to supervision |
| Leadership and governance | Creation of a joint MoPH‑Pivot executive committee for hospital management and transparency; subcommittees for specific projects | Close collaboration with district health managers for the planning and implementation of activities | Community engagement and participation |
[i] 1historic‑HSSi only
[ii] MNCH: maternal, newborn, and child health
[iii] CHW: community health worker
Figure 2
Monthly time series of eight indicators of population health and health system functioning from January 2021to December 2023.
The dashed line represents February 2022, the month when Cyclone Batsirai arrived. Fine lines represent commune‑level means while the bolder lines represent the mean by HSSi‑zone (historic vs. recent). One outlier value has been removed from the graph of vaccination coverage to aid with visualization. Historic‑HSSi refers to the zone benefitting from the intervention prior to July 2021 and recent‑HSSi represents the zone where the intervention began in July 2021.
Table 2
Results of GLMMs estimating the association between the HSSi‑zone, the post‑cyclone period, and the interaction between the two on eight indicators. Rate ratios represent the ratio between the two groups (i.e. historic vs. recent HSSi, post‑cyclone period vs. long term average, and the impact of cyclone on historic vs. recent HSSi) for each indicator. 95% CIs are shown in parentheses.
| INDICATOR | HISTORIC‑HSSI vs. RECENT‑HSSI | POST‑CYCLONE PERIOD vs. LONG‑TERM AVERAGE | HISTORIC‑HSSI X POST‑CYCLONE vs. RECENT‑HSSI X POST‑CYCLONE | |||
|---|---|---|---|---|---|---|
| RATE RATIO | P‑VALUE | RATE RATIO | P‑VALUE | RATE RATIO | P‑VALUE | |
| Malaria | ||||||
| Reported case rate | 0.86 (0.6–1.25) | 0.434 | 1.32 (0.97–1.8) | 0.077 | 0.76 (0.51–1.15) | 0.195 |
| Malaria RDT positivity rate | 0.53 (0.33–0.83) | 0.005 | 0.8 (0.6–1.07) | 0.138 | 0.92 (0.63–1.34) | 0.648 |
| Diarrhea | ||||||
| Reported case rate | 1.55 (1.16–2.05) | 0.003 | 1.15 (0.86–1.53) | 0.344 | 0.9 (0.63–1.28) | 0.554 |
| Proportion of positive consultations | 1.07 (0.83–1.38) | 0.589 | 0.79 (0.56–1.13) | 0.196 | 1.29 (0.83–2) | 0.259 |
| Consultation rate | 1.39 (1.08–1.78) | 0.01 | 1.48 (1.14–1.91) | 0.003 | 0.65 (0.46–0.91) | 0.012 |
| Referral rate | 6.72 (2.03–22.27) | 0.002 | 0.76 (0.57–1.03) | 0.079 | 1.18 (0.85–1.65) | 0.316 |
| DTP31 vaccination coverage | 1.51 (1.15–1.99) | 0.003 | 0.37 (0.18–0.77) | 0.008 | 1.83 (0.72–4.65) | 0.207 |
| UHC‑tracer availability | 1.59 (1.37–1.83) | 0.000 | 1.19 (1.02–1.38) | 0.022 | 0.74 (0.6–0.91) | 0.004 |
[i] 1Diphtheria, tetanus toxoid, and pertussis, indicator representing routine childhood immunization coverage.
Figure 3
The motorized vehicle transportation network remained significantly impacted by flooding three days post‑cyclone.
The motorized vehicle network connecting CSBs to the District hospital (CHRD) on February 8, 2022. Portions of the road network in close proximity to flooding are highlighted. Base Map: ESRI World Street Map.
Figure 4
Long‑term trends in indicators from January 2017 to December 2023.
Indicators are plotted at the commune level (in lighter shaded lines), with loess curves added for each intervention zone to aid with visualization of long‑term trends. One upper outlier each of malaria case rates, vaccination coverage, and malnutrition intake rates have been removed to aid with visualization.