A geographical perspective on access to sexual and reproductive health care for women in rural Africa
Introduction
Utilization of health services significantly impacts health outcomes. It has long been recognized that access to health services is essential to how people utilize such services (Gulliford and Morgan, 2003, Higgs, 2009, Joseph and Phillips, 1984, Meade and Emch, 2010). This is especially true for rural areas of resource-limited developing countries characterized by poor overall health, such as those in rural sub-Saharan Africa (Stock, 1983, Tanser et al., 2006). Improving accessibility of health services for greater quality of life, enhanced overall health and well-being, reduced health inequities and better service to target populations is a central concern in health resource allocation and program planning. Therefore, understanding and evaluating access to health care and its spatial variation are vital for healthcare planners and policy makers.
Though it is widely acknowledged that access is crucial for healthcare utilization, access is defined differently and has different implications in different settings (Aday and Andersen, 1975, Cromley and McLafferty, 2011, Gulliford et al., 2002, Joseph and Phillips, 1984, Wang, 2012). Generally, access can be measured in two distinct, yet interacting dimensions: geographic/spatial and non-spatial (Donabedian, 1973). Geographic access highlights the spatial separation (distance, rivers, forests, mountains, etc.) between health facilities and the population in need of service. Non-spatial access, in contrast, refers to demographic, social-economical and organizational factors (sex, age, education, income, religion, etc.) that facilitate or hinder the acquisition of healthcare. From the perspective of utilization, two types of accessibility can be distinguished: potential and revealed (Joseph and Bantock, 1982, Joseph and Phillips, 1984). The former describes the opportunity to use health services, whereas the latter refers to actual achievement of potential access, that is, utilization.
Of interest in this study is potential geographic access to sexual and reproductive health (SRH) services, and in particular to family planning in rural Africa. It has been found that geographic access to SRH services is an important factor influencing health outcomes such as pregnancy and birth, prenatal and neonatal mortality, maternal morbidity and mortality, and vertical transmission of infectious diseases like HIV/AIDS (Acharya and Cleland, 2000, Rahman et al., 2008, Tanser et al., 2006). As is the case in other types of health care, geographic access to SRH services can be defined in many ways, including travel distance/time/costs (Nemet & Bailey, 2000), gravity-based metrics (Joseph & Bantock, 1982) and more recently, the two-step floating catchment area (2SFCA) (Luo and Wang, 2003, Wang and Luo, 2005). In the context of rural Africa, current research of geographic access to healthcare primarily relies on distance-based measures (Buor, 2003, Noor et al., 2003, Stock, 1983; Tanser et al., 2006). The value of alternative measures is worth further exploration.
Given their capability of managing and processing spatial data, geographic information systems (GIS) are well suited for evaluating geographic access to health services (Cromley and McLafferty, 2011, Higgs, 2004, Meade and Emch, 2010, Rushton, 2003, Wang, 2012, Yao et al., 2012). Desktop mapping makes it easy and straightforward to visualize health data in different spatial representations and under various spatial scales. Also, some spatial operations, such as data aggregation and calculation of travel distance/time/costs, can be easily implemented using readily available functions in GIS. Further, spatial analysis using GIS can provide insights into disparities in geographic access among a population across space, helping identify insufficient health service access and possible influencing factors that otherwise cannot be detected.
The aim of this study is to develop a geographic access index in a GIS environment capable of reflecting important spatial influences and variability to SRH services in rural Africa, using access to family planning in rural areas of Mozambique as an example. The remainder of the paper is structured as follows. The next section provides an overview of current research on access, especially geographic/spatial access, to health services. The study area and data utilized are then described. We then provide a detailed description of the proposed method. An application of the new method to examine geographic access to SRH services is then presented, focusing on variation over space and the impact on actual health care usage by women in rural Mozambique. We conclude with a discussion of the results and implications.
Section snippets
Background
Healthcare access is a multidimensional concept, and in recent years there has been increasing interest and research on access in a number of fields, including hygiene, economics, geography, sociology, and public policy, among others (Cromley and McLafferty, 2011, Gulliford and Morgan, 2003, Joseph and Phillips, 1984). As a result, numerous definitions of access have been proposed in the literature oriented to different academic specialties. One of the earliest definitions explains access in
Data and study area
The data used in this study are from a survey conducted in 2009 in rural areas of four districts (Chibuto, Chokwè, Guíjà and Mandlakaze) of Gaza province in southern Mozambique, an impoverished nation in southeast Africa. The study region covers an area of approximately 5900 square miles with a population of about 625,000, served by fifty-three state-run primary health clinics. The local economy is largely dependent on subsistence agriculture. Due to poor agricultural yields and the proximity
Methods
In this study, spatial information and attribute variables are combined in the definition of geographic access. Specifically, characteristics of health facilities are integrated in a hedonic model to evaluate the overall service quality of health providers, which is then incorporated into a gravity-based model to define access. Spatial variation of geographic access is further explored by Kernel density estimation, a GIS-based spatial analysis technique. Regression analysis is utilized to
Results
The Poisson regression analysis results on patient utilization of family planning for each clinic using relevant variables are summarized in Table 1. It turns out that only one clinic attribute, “the number of nurses”, has a significant influence on the patient flow of the clinics for family planning services. Thus, this attribute is considered most important in defining the service quality of the clinic. Given the fact that the regression is carried out on sample data and considering the
Discussion
As is well known, access is a critical factor impacting health service utilization. Quantitative measures can help to evaluate access and identify deficiencies in service coverage as well as disadvantaged population in subsequent analysis. However, most research has been limited to urban areas (e.g. Lovett et al., 2002, Luo and Wang, 2003, Schuurman et al., 2010) or rural areas in developed countries (e.g. Arcury et al., 2005, Joseph and Bantock, 1982, McGrail and Humphreys, 2009, Nemet and
Conclusion
Improving access to health services is a great concern of government and policy makers striving to enhance overall public health. Spatial patterns of access to health services are complex products of distance effects, environmental influences, socioeconomic factors, individual and community characteristics, etc. The index proposed in our study is effective in revealing potential geographic influences on access to SRH services in rural Mozambique, which cannot be detected by traditional distance
Acknowledgments
We thank the support of the Eunice Kennedy Shriver National Institute of Child Health & Human Development (grants #R21HD048257; R01HD058365; R01HD058365-03S1).
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