Abstract
Community health programs are gaining relevance within national health systems and becoming inherently more complex. To ensure that community health programs lead to equitable geographic access to care, the WHO recommends adapting the target population and workload of community health workers (CHWs) according to the local geographic context and population size of the communities they serve. Geographic optimization could be particularly beneficial for those activities that require CHWs to visit households door-to-door for last mile delivery of care. The goal of this study was to demonstrate how geographic optimization can be applied to inform community health programs in rural areas of the developing world. We developed a decision-making tool based on OpenStreetMap mapping and route optimization algorithms in order to inform the micro-planning and implementation of two kinds of community health interventions requiring door-to-door delivery: mass distribution campaigns and proactive community case management (proCCM) programs. We applied the Vehicle Routing Problem with Time Windows (VRPTW) algorithm to optimize the on-foot routes that CHWs take to visit households in their catchment, using a geographic dataset obtained from mapping on OpenStreetMap comprising over 100,000 buildings and 20,000 km of footpaths in the rural district of Ifanadiana, Madagascar. We found that personnel-day requirements ranged from less than 15 to over 60 per CHW catchment for mass distribution campaigns, and from less than 5 to over 20 for proCCM programs, assuming 1 visit per month. To illustrate how these VRPTW algorithms can be used by operational teams, we developed an "e-health" platform to visualize resource requirements, CHW optimal schedules and itineraries according to customizable intervention designs and hypotheses. Further development and scale-up of these tools could help optimize community health programs and other last mile delivery activities, in line with WHO recommendations, linking a new era of big data analytics with the most basic forms of frontline care in resource poor areas.