Geospatial evaluation of trade-offs between equity in physical access to healthcare and health systems efficiency

Abstract

IntroductionDecisions regarding the geographical placement of healthcare services require consideration of trade-offs between equity and efficiency, but few empirical assessments are available. We applied a novel geospatial framework to study these trade-offs in four African countries.MethodsGeolocation data on population density (a surrogate for efficiency), health centres and cancer referral centres in Kenya, Malawi, Tanzania and Rwanda were obtained from online databases. Travel time to the closest facility (a surrogate for equity) was estimated with 1 km resolution using the Access Mod 5 least cost distance algorithm. We studied associations between district-level average population density and travel time to closest facility for each country using Pearson’s correlation, and spatial autocorrelation using the Global Moran’s I statistic. Geographical clusters of districts with inefficient resource allocation were identified using the bivariate local indicator of spatial autocorrelation.ResultsPopulation density was inversely associated with travel time for all countries and levels of the health system (Pearson’s correlation range, health centres: −0.89 to −0.71; cancer referral centres: −0.92 to −0.43), favouring efficiency. For health centres, negative spatial autocorrelation (geographical clustering of dissimilar values of population density and travel time) was weaker in Rwanda (−0.310) and Tanzania (−0.292), countries with explicit policies supporting equitable access to rural healthcare, relative to Kenya (−0.579) and Malawi (−0.543). Stronger spatial autocorrelation was observed for cancer referral centres (Rwanda: −0.341; Tanzania: −0.259; Kenya: −0.595; Malawi: −0.666). Significant geographical clusters of sparsely populated districts with long travel times to care were identified across countries.ConclusionNegative spatial correlations suggested that the geographical distribution of health services favoured efficiency over equity, but spatial autocorrelation measures revealed more equitable geographical distribution of facilities in certain countries. These findings suggest that even when prioritising efficiency, thoughtful decisions regarding geographical allocation could increase equitable physical access to services.

Availability of essential diagnostics in ten low-income and middle-income countries: results from national health facility surveys

“…If a patient does not have access to facilities, then they would not have access to the diagnostics. As an example, Namibia has poor accessibility to facilities (in terms of access within 2 h for the population), 25 but high availability of diagnostics at the facilities. This study also did not evaluate the number of tests performed or whether skilled staff were available, only that there was functioning equipment.…”

Balancing Equity and Efficiency in the Allocation of Health Resources—Where Is the Middle Ground?

“…On the contrary, Alhassan et al [27] reported that health facilities located in rural parts of western Ghana had higher odds (42.9-52.1%) of being efficient, as compared to those in the capital city (p = 0.002). In a recent study to evaluate the trade-offs between geospatial equity and health systems efficiency in Kenya, Malawi, Tanzania, and Rwanda, Iyer et al [36] found evidence to suggest that in prioritising efficiency, considerate choices with regard to geographical allocation of health resources could enhance equitable physical access to services.…”

Optimising passive surveillance of a neglected tropical disease in the era of elimination: A modelling study

“…This implies that such targets are easily attainable within the geographic extent of our study area. Scaling back to this degree however poses concerns regarding equity of access [ 48 ]. For a disease like g-HAT, which predominantly affects rural populations, severe scaling back to achieve moderate targets could leave remote communities without coverage.…”