title: Assessing early access to care and child survival during a health system strengthening intervention in Mali: a repeated cross sectional survey.
abstract: BACKGROUND
  In 2012, 6.6 million children under age five died worldwide, most from diseases with known means of prevention and treatment. A delivery gap persists between well-validated methods for child survival and equitable, timely access to those methods. We measured early child health care access, morbidity, and mortality over the course of a health system strengthening model intervention in Yirimadjo, Mali. The intervention included Community Health Worker active case finding, user fee removal, infrastructure development, community mobilization, and prevention programming.
  
  
  RESULTS
  We conducted four household surveys using a cluster-based, population-weighted sampling methodology at baseline and at 12, 24, and 36 months. We defined our outcomes as the percentage of children initiating an effective antimalarial within 24 hours of symptom onset, the percentage of children reported to be febrile within the previous two weeks, and the under-five child mortality rate. We compared prevalence of febrile illness and treatment using chi-square statistics, and estimated and compared under-five mortality rates using Cox proportional hazard regression. There was a statistically significant difference in under-five mortality between the 2008 and 2011 surveys; in 2011, the hazard of under-five mortality in the intervention area was one tenth that of baseline (HR 0.10, p<0.0001). After three years of the intervention, the prevalence of febrile illness among children under five was significantly lower, from 38.2% at baseline to 23.3% in 2011 (PR = 0.61, p = 0.0009). The percentage of children starting an effective antimalarial within 24 hours of symptom onset was nearly twice that reported at baseline (PR = 1.89, p = 0.0195).
  
  
  CONCLUSIONS
  Community-based health systems strengthening may facilitate early access to prevention and care and may provide a means for improving child survival.
authors.affiliation: University of California San Francisco School of Medicine, San Francisco, California, United States of America ; Division of Research, Muso, Yirimadjo, Bamako, Mali.
authors.forename: Ari D
authors.initials: AD
authors.lastname: Johnson
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Dana R
authors.initials: DR
authors.lastname: Thomson
authors.affiliation: Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Sidney
authors.initials: S
authors.lastname: Atwood
authors.affiliation: Division of Research, Muso, Yirimadjo, Bamako, Mali.
authors.forename: Ian
authors.initials: I
authors.lastname: Alley
authors.affiliation: University of California San Francisco School of Medicine, San Francisco, California, United States of America ; Division of Research, Muso, Yirimadjo, Bamako, Mali.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Beckerman
authors.affiliation: Division of Research, Muso, Yirimadjo, Bamako, Mali.
authors.forename: Ichiaka
authors.initials: I
authors.lastname: Koné
authors.affiliation: Division of Research, Muso, Yirimadjo, Bamako, Mali.
authors.forename: Djoumé
authors.initials: D
authors.lastname: Diakité
authors.affiliation: Malian Ministry of Health, Bamako, Mali.
authors.forename: Hamed
authors.initials: H
authors.lastname: Diallo
authors.affiliation: Malian Ministry of Health, Bamako, Mali.
authors.forename: Boubacar
authors.initials: B
authors.lastname: Traoré
authors.affiliation: Malian Ministry of Health, Bamako, Mali.
authors.forename: Klenon
authors.initials: K
authors.lastname: Traoré
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America ; Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Paul E
authors.initials: PE
authors.lastname: Farmer
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America ; Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America ; Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Megan
authors.initials: M
authors.lastname: Murray
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America ; Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Joia
authors.initials: J
authors.lastname: Mukherjee
mesh_terms: D002648:Child; D046688:Child Mortality; D002669:Child Welfare; D002675:Child, Preschool; D018672:Community Health Planning; D003150:Community Health Workers; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008302:Mali