Validation de spécifications de systèmes d'information avec Alloy

Le présent mémoire propose une investigation approfondie de l’analyseur Alloy afin de juger son adaptabilité en tant que vérificateur de modèles. Dans un premier temps, l’étude dresse un tableau comparatif de six vérificateurs de modèles, incluant Alloy, afin de déterminer lequel d’entre eux est le plus apte à résoudre les problématiques de sécurité fonctionnelle posées par les systèmes d’information. En conclusion de cette première phase, Alloy émerge comme l’un des analyseurs les plus performants pour vérifier les modèles sur lesquels se fondent les systèmes d’information. Dans un second temps, et sur la base des problématiques rencontrées au cours de cette première phase, l’étude rapporte une série d’idiomes pour, d’une part, présenter une manière optimisée de spécifier des traces et, d’autre part, trouver des recours afin de contourner les limitations imposées par Alloy. À ces fins, le mémoire propose deux nouveaux cas d’espèce, ceux d’une cuisinière intelligente et d’une boîte noire, afin de déterminer si oui ou non l’analyseur est capable de gérer les systèmes dynamiques possédant de nombreuses entités avec autant d’efficacité que les systèmes qui en possèdent moins. En conclusion, le mémoire rapporte que Alloy est un bon outil pour vérifier des systèmes dynamiques mais que sa version récente, DynAlloy, peut être encore mieux adapté pour le faire puisque précisément conçu pour faire face aux spécificités de ce type de système. Le mémoire s’achève sur une présentation sommaire de ce dernier outil

Validation de spécifications de systèmes d'information avec Alloy

Le présent mémoire propose une investigation approfondie de l’analyseur Alloy afin de juger son adaptabilité en tant que vérificateur de modèles. Dans un premier temps, l’étude dresse un tableau comparatif de six vérificateurs de modèles, incluant Alloy, afin de déterminer lequel d’entre eux est le plus apte à résoudre les problématiques de sécurité fonctionnelle posées par les systèmes d’information. En conclusion de cette première phase, Alloy émerge comme l’un des analyseurs les plus performants pour vérifier les modèles sur lesquels se fondent les systèmes d’information. Dans un second temps, et sur la base des problématiques rencontrées au cours de cette première phase, l’étude rapporte une série d’idiomes pour, d’une part, présenter une manière optimisée de spécifier des traces et, d’autre part, trouver des recours afin de contourner les limitations imposées par Alloy. À ces fins, le mémoire propose deux nouveaux cas d’espèce, ceux d’une cuisinière intelligente et d’une boîte noire, afin de déterminer si oui ou non l’analyseur est capable de gérer les systèmes dynamiques possédant de nombreuses entités avec autant d’efficacité que les systèmes qui en possèdent moins. En conclusion, le mémoire rapporte que Alloy est un bon outil pour vérifier des systèmes dynamiques mais que sa version récente, DynAlloy, peut être encore mieux adapté pour le faire puisque précisément conçu pour faire face aux spécificités de ce type de système. Le mémoire s’achève sur une présentation sommaire de ce dernier outil

Madagascar can build stronger health systems to fight plague and prevent the next epidemic

International audienc

Assessing trends in the content of maternal and child care following a health system strengthening initiative in rural Madagascar: A longitudinal cohort study

International audienceAbstractBackground In order to reach the health-related Sustainable Development Goals (SDGs) by 2030, gains attained in access to primary healthcare must be matched by gains in the quality of services delivered. Despite the broad consensus around the need to address quality, studies on the impact of health system strengthening (HSS) have focused predominantly on measures of healthcare access. Here, we examine changes in the content of maternal and child care as a proxy for healthcare quality, to better evaluate the effectiveness of an HSS intervention in a rural district of Madagascar. The intervention aimed at improving system readiness at all levels of care (community health, primary health centers, district hospital) through facility renovations, staffing, equipment, and training, while removing logistical and financial barri- ers to medical care (e.g., ambulance network and user-fee exemptions).Methods and findings We carried out a district-representative open longitudinal cohort study, with surveys admin- istered to 1,522 households in the Ifanadiana district of Madagascar at the start of the HSS intervention in 2014, and again to 1,514 households in 2016. We examined changes in healthcare seeking behavior and outputs for sick-child care among children <5 years old, as well as for antenatal care and perinatal care among women aged 15–49. We used a differ- ence-in-differences (DiD) analysis to compare trends between the intervention group (i.e., people living inside the HSS catchment area) and the non-intervention comparison group (i.e., the rest of the district). In addition, we used health facility–based surveys, monitoring service availability and readiness, to assess changes in the operational capacities of facilities supported by the intervention. The cohort study included 657 and 411 children (mean age = 2 years) reported to be ill in the 2014 and 2016 surveys, respectively (27.8% and 23.8% in the intervention group for each survey), as well as 552 and 524 women (mean age = 28 years) reported to have a live birth within the previous two years in the 2014 and 2016 surveys, respectively (31.5% and 29.6% in the intervention group for each survey). Over the two-year study period, the proportion of people who reported seeking care at health facilities experienced a relative change of +51.2% (from 41.4% in 2014 to 62.5% in 2016) and −7.1% (from 30.0% to 27.9%) in the intervention and non-intervention groups, respectively, for sick-child care (DiD p-value = 0.01); +11.4% (from 78.3% to 87.2%), and +10.3% (from 67.3% to 74.2%) for antenatal care (p-value = 0.75); and +66.2% (from 23.1% to 38.3%) and +28.9% (from 13.9% to 17.9%) for perinatal care (p-value = 0.13). Most indi- cators of care content, including rates of medication prescription and diagnostic test admin- istration, appeared to increase more in the intervention compared to in the non-intervention group for the three areas of care we assessed. The reported prescription rate for oral rehy- dration therapy among children with diarrhea changed by +68.5% (from 29.6% to 49.9%) and −23.2% (from 17.8% to 13.7%) in the intervention and non-intervention groups, respec- tively (p-value = 0.05). However, trends observed in the care content varied widely by indica- tor and did not always match the large apparent increases observed in care seeking behavior, particularly for antenatal care, reflecting important gaps in the provision of essen- tial health services for individuals who sought care. The main limitation of this study is that the intervention catchment was not randomly allocated, and some demographic indicators were better for this group at baseline than for the rest of the district, which could have impacted the trends observed. ConclusionUsing a district-representative longitudinal cohort to assess the content of care delivered to the population, we found a substantial increase over the two-year study period in the pre- scription rate for ill children and in all World Health Organization (WHO)-recommended peri- natal care outputs assessed in the intervention group, with more modest changes observed in the non-intervention group. Despite improvements associated with the HSS intervention, this study highlights the need for further quality improvement in certain areas of the district’s healthcare system. We show how content of care, measured through standard population- based surveys, can be used as a component of HSS impact evaluations, enabling health- care leaders to track progress as well as identify and address specific gaps in the provision of services that extend beyond care access

Assessing trends in the content of maternal and child care following a health system strengthening initiative in rural Madagascar: A longitudinal cohort study

International audienceAbstractBackground In order to reach the health-related Sustainable Development Goals (SDGs) by 2030, gains attained in access to primary healthcare must be matched by gains in the quality of services delivered. Despite the broad consensus around the need to address quality, studies on the impact of health system strengthening (HSS) have focused predominantly on measures of healthcare access. Here, we examine changes in the content of maternal and child care as a proxy for healthcare quality, to better evaluate the effectiveness of an HSS intervention in a rural district of Madagascar. The intervention aimed at improving system readiness at all levels of care (community health, primary health centers, district hospital) through facility renovations, staffing, equipment, and training, while removing logistical and financial barri- ers to medical care (e.g., ambulance network and user-fee exemptions).Methods and findings We carried out a district-representative open longitudinal cohort study, with surveys admin- istered to 1,522 households in the Ifanadiana district of Madagascar at the start of the HSS intervention in 2014, and again to 1,514 households in 2016. We examined changes in healthcare seeking behavior and outputs for sick-child care among children <5 years old, as well as for antenatal care and perinatal care among women aged 15–49. We used a differ- ence-in-differences (DiD) analysis to compare trends between the intervention group (i.e., people living inside the HSS catchment area) and the non-intervention comparison group (i.e., the rest of the district). In addition, we used health facility–based surveys, monitoring service availability and readiness, to assess changes in the operational capacities of facilities supported by the intervention. The cohort study included 657 and 411 children (mean age = 2 years) reported to be ill in the 2014 and 2016 surveys, respectively (27.8% and 23.8% in the intervention group for each survey), as well as 552 and 524 women (mean age = 28 years) reported to have a live birth within the previous two years in the 2014 and 2016 surveys, respectively (31.5% and 29.6% in the intervention group for each survey). Over the two-year study period, the proportion of people who reported seeking care at health facilities experienced a relative change of +51.2% (from 41.4% in 2014 to 62.5% in 2016) and −7.1% (from 30.0% to 27.9%) in the intervention and non-intervention groups, respectively, for sick-child care (DiD p-value = 0.01); +11.4% (from 78.3% to 87.2%), and +10.3% (from 67.3% to 74.2%) for antenatal care (p-value = 0.75); and +66.2% (from 23.1% to 38.3%) and +28.9% (from 13.9% to 17.9%) for perinatal care (p-value = 0.13). Most indi- cators of care content, including rates of medication prescription and diagnostic test admin- istration, appeared to increase more in the intervention compared to in the non-intervention group for the three areas of care we assessed. The reported prescription rate for oral rehy- dration therapy among children with diarrhea changed by +68.5% (from 29.6% to 49.9%) and −23.2% (from 17.8% to 13.7%) in the intervention and non-intervention groups, respec- tively (p-value = 0.05). However, trends observed in the care content varied widely by indica- tor and did not always match the large apparent increases observed in care seeking behavior, particularly for antenatal care, reflecting important gaps in the provision of essen- tial health services for individuals who sought care. The main limitation of this study is that the intervention catchment was not randomly allocated, and some demographic indicators were better for this group at baseline than for the rest of the district, which could have impacted the trends observed. ConclusionUsing a district-representative longitudinal cohort to assess the content of care delivered to the population, we found a substantial increase over the two-year study period in the pre- scription rate for ill children and in all World Health Organization (WHO)-recommended peri- natal care outputs assessed in the intervention group, with more modest changes observed in the non-intervention group. Despite improvements associated with the HSS intervention, this study highlights the need for further quality improvement in certain areas of the district’s healthcare system. We show how content of care, measured through standard population- based surveys, can be used as a component of HSS impact evaluations, enabling health- care leaders to track progress as well as identify and address specific gaps in the provision of services that extend beyond care access

Measuring the burden of SARS-CoV-2 infection among persons living with HIV and healthcare workers and its impact on service delivery in Mozambique: protocol of a prospective cohort study

Introduction As COVID-19 continues to spread globally and within Mozambique, its impact among immunosuppressed persons, specifically persons living with HIV (PLHIV), and on the health system is unknown in the country. The ‘COVid and hIV’ (COVIV) study aims to investigate: (1) the seroprevalence and seroincidence of SARS-CoV-2 among PLHIV and healthcare workers providing HIV services; (2) knowledge, attitudes, practices and perceptions regarding SARS-CoV-2 infection; (3) the pandemic’s impact on HIV care continuum outcomes and (4) facility level compliance with national COVID-19 guidelines.Methods and analysis A multimethod study will be conducted in a maximum of 11 health facilities across Mozambique, comprising four components: (1) a cohort study among PLHIV and healthcare workers providing HIV services to determine the seroprevalence and seroincidence of SARS-CoV-2, (2) a structured survey to assess knowledge, attitudes, perceptions and practices regarding COVID-19 disease, (3) analysis of aggregated patient data to evaluate retention in HIV services among PLHIV, (4) an assessment of facility implementation of infection prevention and control measures.Ethics and dissemination Ethical approval was obtained from the National Health Bioethics Committee, and institutional review boards of implementing partners. Study findings will be discussed with local and national health authorities and key stakeholders and will be disseminated in clinical and scientific forums.Trial registration number NCT05022407

Child malnutrition in Ifanadiana district, Madagascar: associated factors and timing of growth faltering ahead of a health system strengthening intervention

ABSTRACT Background:: Child malnutrition, a leading cause of death and disability worldwide, is particularly severe in Madagascar, where 47% of children under 5 years are stunted (low height-for-age) and 8% are wasted (low weight-for-height). Widespread poverty and a weak health system have hindered attempts to implement life-saving malnutrition interventions in Madagascar during critical periods for growth faltering. Objective:: This study aimed to shed light on the most important factors associated with child malnutrition, both acute and chronic, and the timing of growth faltering, in Ifanadiana, a rural district of Madagascar. Methods:: We analyzed data from a 2014 district-representative cluster household survey, which had information on 1175 children ages 6 months to 5 years. We studied the effect of child health, birth history, maternal and paternal health and education, and household wealth and sanitation on child nutritional status. Variables associated with stunting and wasting were modeled separately in multivariate logistic regressions. Growth faltering was modeled by age range. All analyses were survey-adjusted. Results:: Stunting was associated with increasing child age (OR = 1.03 (95%CI 1.02–1.04) for each additional month), very small birth size (OR = 2.32 (1.24–4.32)), low maternal weight (OR = 0.94 (0.91–0.97) for each kilogram, kg) and height (OR = 0.95 (0.92–0.99) for each centimeter), and low paternal height (OR = 0.95 (0.92–0.98)). Wasting was associated with younger child age (OR = 0.98 (0.97–0.99)), very small birth size (OR = 2.48 (1.23–4.99)), and low maternal BMI (OR = 0.84 (0.75–0.94) for each kg/m2). Height-for-age faltered rapidly before 24 months, then slowly until age 5 years, whereas weight-for-height faltered rapidly before 12 months, then recovered gradually until age 5 years but did not reach the median. Conclusion:: Intergenerational transmission of growth faltering and early life exposures may be important determinants of malnutrition in Ifanadiana. Timing of growth faltering, in the first 1000 days, is similar to international populations; however, child growth does not recover to the median

Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar

Introduction: The Sustainable Development Goals framed an unprecedented commitment to achieve global convergence in child and maternal mortality rates through 2030. To meet those targets, essential health services must be scaled via integration with strengthened health systems. This is especially urgent in Madagascar, the country with the lowest level of financing for health in the world. Here, we present an interim evaluation of the first 2 years of a district-level health system strengthening (HSS) initiative in rural Madagascar, using estimates of intervention coverage and mortality rates from a district-wide longitudinal cohort. Methods: We carried out a district representative household survey at baseline of the HSS intervention in over 1500 households in Ifanadiana district. The first follow-up was after the first 2 years of the initiative. For each survey, we estimated maternal, newborn and child health (MNCH) coverage, healthcare inequalities and child mortality rates both in the initial intervention catchment area and in the rest of the district. We evaluated changes between the two areas through difference-in-differences analyses. We estimated annual changes in health centre per capita utilisation from 2013 to 2016. Results: The intervention was associated with 19.1% and 36.4% decreases in under-five and neonatal mortality, respectively, although these were not statistically significant. The composite coverage index (a summary measure of MNCH coverage) increased by 30.1%, with a notable 63% increase in deliveries in health facilities. Improvements in coverage were substantially larger in the HSS catchment area and led to an overall reduction in healthcare inequalities. Health centre utilisation rates in the catchment tripled for most types of care during the study period. Conclusion: At the earliest stages of an HSS intervention, the rapid improvements observed for Ifanadiana add to preliminary evidence supporting the untapped and poorly understood potential of integrated HSS interventions on population health