Background
Methods
Study area
Level | Population Capacity | Services Offered |
---|---|---|
Health Center II | 5000 | “Preventative, promotive, and outpatient curative services, and emergency maternal deliveries |
Health Center III | 20,000 | All the above services. In addition, provides inpatient, maternal, and laboratory services |
Health Center IV | 100,000 | All the above services. In addition, provides emergency surgery, blood transfusion, laboratory services. Also, supervises levels 2 and 3. |
General Hospital | 500,000 | All the above services, but more comprehensive than HC 4. In addition, provides medicine, surgery, obstetrics, and gynecology, pediatrics, family medicine, and X-ray (plane and mobile) |
Regional Referral Hospital | 2,000,000 | All the above services. In addition, provides specialized services (Medicine, Surgery, Obstetrics, and Gynecology, Pediatrics, ENT, Ophthalmology, Orthopedics, Anesthesia, Pathology, Psychiatry, Dentistry, and Community Medicine. Have specialists, train nurses, have a blood bank, do basic and applied research and provide engineering services to facilities in its health zone. |
National Referral Hospital | 10,000,000 | All the above services, but more comprehensive and advanced than regional hospital. For instance, national hospitals offer advanced diagnostic services such as MRI and CT scans; they have super-specialists, and train doctors, pharmacists, dental surgeons, and graduate nurses and carry out advanced research.” |
Approach
Health-seeking behavior associated with wealth index analysis
Geospatial data preparation
Variable | Data Type | Resolution | Citation |
---|---|---|---|
Digital Elevation Model | Raster | 90 m | [34] |
2020 UN Adjusted Human Population Count | Raster | 1 km | [35] |
Roads | Vector | N/A | [36] |
2016 Sentinel-2 Landcover | Raster | 30 m | [37] |
Health Facility Locations | Vector | N/A | [38] |
Protected Areas | Vector | N/A | [39] |
Health facility accessibility analysis
Landcover | Speed (km/hr) | ||
---|---|---|---|
Walking Scenario | Bicycle Scenario | Driving Scenario | |
Primary Road | 6 | 12 | 100 |
Secondary Road | 6 | 12 | 50 |
Tertiary Road | 6 | 12 | 30 |
Forests | 2 | 2 | 2 |
Shrublands | 2 | 2 | 2 |
Grassland | 5 | 5 | 5 |
Cropland | 4 | 4 | 4 |
Regularly Flooded Areas or Aquatic Vegetation | 0 | 0 | 0 |
Sparse Vegetation and Mosses | 3 | 3 | 3 |
Bare Areas | 5 | 12 | 5 |
Built up Areas | 5 | 12 | 5 |
Open Water | 0 | 0 | 0 |
Hotspot cluster analysis
Statistical modeling data preparation
Random forest modeling
Linear mixed-effects modeling
Results
Health facility accessibility analysis
Health Unit Level | Walk | Bicycle | Drive |
---|---|---|---|
Health Center Level II | 71.73% (60.01–79.69) | 90.57% (83.68–97.96) | 97.10% (95.28–97.64) |
Health Center Level III | 53.05% (47.56–54.55) | 80.57% (70.03–87.17) | 96.20% (93.36–97.06) |
Health Center Level IV | 27.85% (22.80–33.00) | 46.56% (36.40–56.11) | 90.89% (83.68–94.02) |
General Hospital | 13.69% (11.50–14.84) | 24.83% (19.81–30.25) | 76.37% (64.42–83.49) |
Regional Referral Hospital | 7.59% (6.08–9.14) | 13.87% (11.97–15.85) | 53.42% (41.19–64.42) |
National Referral Hospital | 5.21% (4.61–5.22) | 7.74% (6.98–8.57) | 15.90% (14.04–17.64) |
Hotspot cluster analysis
Random forest modeling
Importance Average (rank) | Accuracy Metrics | |||||||
---|---|---|---|---|---|---|---|---|
HC Level | Scenario | Population Density | Poverty | Sub Region | MAE | RMSE | R2 | Mtry |
HC II | 1 | 1018 (1) | 457 (2) | 96 (3) | 30.96 | 44.47 | 0.54 | 2 |
2 | 274 (1) | 265 (2) | 103 (3) | 21.42 | 30.12 | 0.41 | 2 | |
HC III | 1 | 1346 (1) | 988 (2) | 221 (3) | 39.18 | 53.64 | 0.54 | 2 |
2 | 183 (1) | 174 (2) | 50 (3) | 17.6 | 23.22 | 0.45 | 2 | |
HC IV | 1 | 5904 (1) | 2248 (2) | 250 (3) | 67.53 | 88.95 | 0.5 | 3 |
2 | 876 (1) | 455 (2) | 180 (3) | 30.85 | 39.3 | 0.49 | 3 | |
Hospital | 1 | 13,657 (1) | 5253 (2) | 3208 (3) | 105.77 | 139.37 | 0.52 | 3 |
2 | 2729 (1) | 1356 (2) | 850 (3) | 51.43 | 68.74 | 0.49 | 3 | |
RRH | 1 | 68,744 (1) | 17,289 (2) | 12,533 (3) | 158.22 | 215.48 | 0.69 | 3 |
2 | 13,658 (1) | 4170 (2) | 2733 (3) | 84.42 | 111.87 | 0.63 | 2 | |
NRH | 1 | 104,105 (2) | 37,625 (3) | 377,319 (1) | 297.31 | 426.44 | 0.9 | 2 |
2 | 29,039 (2) | 10,445 (3) | 95,322 (1) | 122.68 | 170.74 | 0.93 | 3 |
Linear mixed-effects modeling
Health Center II | Health Center III | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
Estimate | SE | CI | t | p | Estimate | SE | CI | t | p | |
(Intercept) | 74.11 | 2.50 | 69.21–79.01 | 29.66 | < 0.001 | 99.44 | 5.21 | 89.23–109.66 | 19.08 | < 0.001 |
Poverty | 102.20 | 8.56 | 85.43–118.98 | 11.94 | < 0.001 | 203.81 | 10.07 | 184.07–223.54 | 20.24 | < 0.001 |
Population Density | − 261.91 | 8.68 | − 278.93 –− 244.90 | −30.17 | < 0.001 | − 288.61 | 10.18 | − 308.56 –− 268.66 | −28.35 | < 0.001 |
Interaction | − 628.20 | 39.88 | − 706.36 –− 550.04 | −15.75 | < 0.001 | − 725.85 | 46.34 | − 816.67 –− 635.03 | −15.66 | < 0.001 |
Random Effects | ||||||||||
σ2 | 2532.11 | 3345.50 | ||||||||
τ00 | 59.85 SubRegion | 286.93 SubRegion | ||||||||
ICC | 0.02 | 0.08 | ||||||||
MAE | 33.71 | 43.97 | ||||||||
RMSE | 48.76 | 58.96 | ||||||||
R2 | 0.45 | 0.45 | ||||||||
Health Center IV | General Hospital | |||||||||
Estimate | SE | CI | t | p | Estimate | SE | CI | t | p | |
(Intercept) | 198.92 | 7.25 | 184.71–213.13 | 27.44 | < 0.001 | 357.85 | 17.55 | 323.46–392.24 | 20.39 | < 0.001 |
Poverty | 282.95 | 16.53 | 250.56–315.34 | 17.12 | < 0.001 | 485.22 | 30.37 | 425.71–544.74 | 15.98 | < 0.001 |
Population Density | − 431.04 | 16.72 | − 463.80 – − 398.28 | −25.79 | < 0.001 | − 523.27 | 30.13 | − 582.32 – − 464.22 | −17.37 | < 0.001 |
Interaction | − 403.72 | 76.22 | − 553.12 –− 254.32 | −5.30 | < 0.001 | |||||
Random Effects | ||||||||||
σ2 | 9087.88 | 30,371.98 | ||||||||
τ00 | 545.83 SubRegion | 3289.19 SubRegion | ||||||||
ICC | 0.06 | 0.1 | ||||||||
MAE | 75.86 | 134.15 | ||||||||
RMSE | 97.89 | 172.46 | ||||||||
R2 | 0.39 | 0.26 | ||||||||
Regional Referral Hospital | National Referral Hospital | |||||||||
Estimate | SE | CI | t | p | Estimate | SE | CI | t | p | |
(Intercept) | 726.66 | 32.19 | 663.56–789.76 | 22.57 | < 0.001 | 2806.11 | 326.60 | 2165.99–3446.23 | 8.59 | < 0.001 |
Poverty | 770.02 | 94.14 | 585.50–954.53 | 8.18 | < 0.001 | |||||
Population Density | − 1593.59 | 51.83 | − 1695.18 –− 1492.00 | −30.74 | < 0.001 | − 821.41 | 95.07 | − 1007.74 –−635.07 | −8.64 | < 0.001 |
Interaction | 1689.33 | 430.99 | 844.59–2534.06 | 3.92 | < 0.001 | |||||
Random Effects | ||||||||||
σ2 | 100,144.94 | 286,676.04 | ||||||||
τ00 | 11,077.07 SubRegion | 1,172,295.43 SubRegion | ||||||||
ICC | 0.1 | 0.8 | ||||||||
MAE | 237.56 | 432.30 | ||||||||
RMSE | 310.62 | 557.29 | ||||||||
R2 | 0.35 | 0.83 |
Health Center II | Health Center III | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
Estimate | SE | CI | t | p | Estimate | SE | CI | t | p | |
(Intercept) | −55.42 | 3.35 | −61.99 –−48.86 | −16.54 | < 0.001 | −40.55 | 2.64 | −45.72 –−35.38 | −15.38 | < 0.001 |
Poverty | − 101.74 | 5.83 | − 113.17 –−90.31 | −17.44 | < 0.001 | −84.59 | 4.54 | −93.48 –−75.69 | −18.64 | < 0.001 |
Population Density | 95.74 | 5.89 | 84.19–107.30 | 16.24 | < 0.001 | 91.61 | 4.59 | 82.62–100.60 | 19.97 | < 0.001 |
Interaction | 188.73 | 26.81 | 136.18–241.29 | 7.04 | < 0.001 | 221.43 | 20.86 | 180.54–262.32 | 10.61 | < 0.001 |
Random Effects | ||||||||||
σ2 | 1118.22 | 676.78 | ||||||||
τ00 | 119.50 SubRegion | 74.02 SubRegion | ||||||||
ICC | 0.1 | 0.1 | ||||||||
MAE | 24.88 | 19.65 | ||||||||
RMSE | 34.22 | 26.21 | ||||||||
R2 | 0.24 | 0.30 | ||||||||
Health Center IV | General Hospital | |||||||||
Estimate | SE | CI | t | p | Estimate | SE | CI | t | p | |
(Intercept) | −91.24 | 3.84 | −98.76 – −83.71 | −23.76 | < 0.001 | − 174.03 | 9.37 | − 192.39 –− 155.67 | −18.58 | < 0.001 |
Poverty | − 123.33 | 8.06 | − 139.12 –−107.54 | −15.31 | < 0.001 | − 228.60 | 15.24 | − 258.47 –− 198.73 | − 15.00 | < 0.001 |
Population Density | 151.75 | 8.00 | 136.08–167.43 | 18.97 | < 0.001 | 194.28 | 15.40 | 164.09–224.47 | 12.61 | < 0.001 |
Interaction | −330.01 | 70.03 | − 467.27 –−192.75 | −4.71 | < 0.001 | |||||
Random Effects | ||||||||||
σ2 | 2153.57 | 7620.12 | ||||||||
τ00 | 155.30 SubRegion | 938.09 SubRegion | ||||||||
ICC | 0.07 | 0.11 | ||||||||
MAE | 36.64 | 66.81 | ||||||||
RMSE | 46.68 | 86.18 | ||||||||
R2 | 0.28 | 0.21 | ||||||||
Regional Referral Hospital | National Referral Hospital | |||||||||
Estimate | SE | CI | t | p | Estimate | SE | CI | t | p | |
(Intercept) | − 354.7 | 15.21 | − 384.52 – − 324.89 | −23.32 | < 0.001 | − 1427.98 | 163.75 | − 1748.93 –− 1107.04 | −8.72 | < 0.001 |
Poverty | − 341.30 | 42.98 | −425.53 –− 257.07 | −7.94 | < 0.001 | |||||
Population Density | 706.79 | 25.92 | 655.98–757.59 | 27.27 | < 0.001 | 326.25 | 43.40 | 241.19–411.31 | 7.52 | < 0.001 |
Interaction | − 1360.50 | 196.74 | − 1746.12 –− 974.89 | −6.92 | < 0.001 | |||||
Random Effects | ||||||||||
σ2 | 25,098.17 | 59,736.23 | ||||||||
τ00 | 2464.05 SubRegion | 294,736.58 SubRegion | ||||||||
ICC | 0.09 | 0.83 | ||||||||
MAE | 119.80 | 202.78 | ||||||||
RMSE | 155.26 | 253.47 | ||||||||
R2 | 0.28 | 0.85 |
Performance comparison between random forest and linear mixed-effects models
HC Level | Scenario | MAE | RMSE | R2 |
---|---|---|---|---|
HC II | 1 | −2.75 | −4.29 | 0.09 |
2 | −3.46 | −4.10 | 0.17 | |
HC III | 1 | −4.79 | −5.32 | 0.09 |
2 | −2.05 | −2.99 | 0.15 | |
HC IV | 1 | −8.33 | −8.94 | 0.11 |
2 | −5.79 | −7.38 | 0.21 | |
Hospital | 1 | −28.71 | −33.09 | 0.25 |
2 | −15.38 | −17.44 | 0.28 | |
RRH | 1 | −78.88 | −94.62 | 0.34 |
2 | −35.38 | −43.39 | 0.35 | |
NRH | 1 | − 134.99 | − 130.85 | 0.07 |
2 | −80.1 | −82.73 | 0.08 |