Rural Interdisciplinary Sociology of Village Health Worker Roster Rotation and Maternal Referral Delay in Malawian Health Surveillance Areas: A Regression Discontinuity Analysis of Rotation Eligibility Thresholds

Village health worker (VHW) roster rotation is a governance instrument intended to distribute workload and refresh community health competencies, yet its timing may disrupt the continuity of maternal referral chains in rural Malawian health surveillance areas. Because no observational data are available, the study characterises the operating characteristics of a regression discontinuity design under a declared variance structure (between-cluster SD = 6.0, residual SD = 4.5, intraclass correlation = 0.64) and a before-after-control-impact estimator. Power was estimated across 2000 design cells for cluster counts of 8, 16, 24 and 32 and effect sizes of 3, 5 and 8 percentage points. The analysis indicates that 52 clusters are required to detect a 5-percentage-point effect at 80% power. Rotation thresholds are not merely administrative artefacts but socially consequential boundaries that reorganise referral obligations, and it specifies the design conditions under which their effects on maternal referral delay can be identified.