ACCESSIBILITY, UTILIZATION AND SPATIAL PLANNING OF HEALTH CARE FACILITIES DR. SHERIF AMER

LEARNING OBJECTIVES At the end of this lecture the course participant will be able to: 1. Explain what social services are and describe the main principles that are used to guide their provision 2. Give examples of different types of social services and clarify why a proper geographic distribution of health facilities is important 3. Characterize the main components of the accessibility concept and the role of NMT therein 4. Comprehend the added value of GIS as a spatial planning tool for health care provision

LECTURE OVERVIEW Part 1: Theory 1. Health care as a social service 2. Accessibility concept Part 2: Example Dar es Salaam experience 1. Objectives of research 2. Data collection 3. Health seeking behavior 4. Diagnostics identifying spatial inequalities 5. Prescription prioritizing interventions

LECTURE OVERVIEW Part 1: Theory 1. Health care as a social service 2. Accessibility concept

WHAT ARE SOCIAL SERVICES?

WHAT ARE SOCIAL SERVICES? Activities provided with the aim of improving social welfare health care and education police and fire protection, cultural and recreational services Important interactions exist between social advancement and economic development

IMPORTANCE OF SOCIAL SERVICES Health every year 10 million children in the developing world die from readily preventable and treatable diseases ill health serious barrier to economic and social development Education 113 million children out of school (60% girls) more education = better prospects

IMPORTANCE OF SOCIAL SERVICES Incidence of malaria Expenditure on health care ($)

DISTRIBUTING SCARCE RESOURCES Need to decide on amount and nature of resources for social service provision (costs) Need to decide how to best satisfy needs of society (benefits) Need to decide how resources are best distributed amongst members of society (achieve balance between benefits & costs) Questions are economic, political and geographic in nature (provided at particular locations in geographical space)

CHALLENGE: DISTRIBUTING SCARCE RESOURCES

GUIDING PRINCIPLES Equity: distribute services among the population in way considered fair and socially just Effectiveness: services provided should offer real benefit; how well are intended objectives achieved, quality Efficiency: obtain highest output from a finite level of resources (costs/benefits; cost recovery) Difficulty: complex trade-offs

SOCIAL SERVICES HAVE A SPATIAL DIMENSION

GUIDING PRINCIPLES: SPATIAL PERSPECTIVE Spatial Equity: distribute services among the population in spatial way considered fair and socially just Spatial Effectiveness: services provided at particular locations should offer real benefit Spatial Efficiency: Organize the spatial configuration of supply to obtain highest output from a finite level of resources Difficulty: complex spatial trade-offs

LECTURE OVERVIEW Part 1: Theory 1. Health care as a social service 2. Accessibility concept

HOW TO EVALUATE EQUITY & EFFICIENCY INDICATORS SPATIALLY? Accessibility concept: the ability and ease of people to overcome the friction of distance to avail themselves of services at fixed points in space People Transport Activities Preference Gender & Mode Price & Location Type Age Convenience Attractiveness Affordability Speed Car ownership Congestion After Moseley, 1976 varies according to characteristics of people, activity and transportation link outcome of combined characteristics of the three components

CLASSIFICATION OF ACCESSIBILITY MEASURES (Higgs, 2005)

ACCESSIBILITY CONCEPT CAN BE USED TO Secure a geographical match between resource needs and resource allocation analyze existing situation prioritize planning interventions evaluate expected impacts Deals with questions like: how many school locations are required to meet a service level? what is the best place for a new health facility? which police stations can be closed without negative effects? which health facility needs to be upgraded?

LECTURE OVERVIEW Part 1: Theory 1. Health care as a social service 2. Accessibility concept Part 2: Example Dar es Salaam experience 1. Objectives of research 2. Data collection (spatial + health seeking behavior) 3. Diagnostics identifying spatial inequalities 4. Prescription prioritizing interventions 5. Assessing potential impacts

LECTURE OVERVIEW Part 1: Theory 1. Health care as a social service 2. Accessibility concept Part 2: Example Dar es Salaam experience 1. Objectives of research 2. Data collection (spatial + health seeking behavior) 3. Health seeking behavior 4. Diagnostics identifying spatial inequalities 5. Prescription prioritizing interventions

HEALTH SERVICES PLANNING DSM Main objectives: to develop a GIS-based planning approach that can identify spatial inequality and inefficiency and suggest spatially just intervention priorities to analyze observed socio-spatial patterns of user-provider interaction on the basis of empirical data on health care utilization

PRIMARY HEALTH CARE APPROACH Making essential health care available to all in an affordable way (widely adopted) Guiding principles: equitable, effective and efficient provision of health services equity: distribute services in way considered fair and socially just effectiveness: services should offer real benefit efficiency: obtain highest output from a finite level of resources

CONTEXT: THE URBAN HEALTH CRISIS Increasing need for medical care in urban areas high urban growth rates urbanization of poverty high levels of morbidity & mortality (large intra-urban differences) Declining carrying capacity of public health systems weak economic performance international call for privatization scarce resources for public health care

URBAN EXPANSION Growth largely informal

LECTURE OVERVIEW Part 1: Theory 1. Health care as a social service 2. Accessibility concept Part 2: Example Dar es Salaam experience 1. Objectives of research 2. Collecting spatial and health seeking data 3. Health seeking behavior 4. Identify spatial inequalities (diagnosis) 5. Prioritize interventions (prescription)

HOW TO EVALUATE EQUITY & EFFICIENCY INDICATORS SPATIALLY? Accessibility concept: the ability and ease of people to overcome the friction of distance to avail themselves of services at fixed points in space People Transport Activities Preference Gender & Mode Price & Location Type Age Convenience Attractiveness Affordability Speed Car ownership Congestion After Moseley, 1976 varies according to characteristics of people, activity and transportation link outcome of combined characteristics of the three components

MODEL SPATIALLY DISAGGREGATE DEMAND - NEED People Preference Gender Age Affordability Car ownership

MODEL FRICTION OF MOVEMENT (Euclidian, network) Transport Price Convenience Speed Physical network Public transport network Physical network Congestion Line A Alighting time Stop time Waiting time Driving time between stop Alighting time Stop time Waiting time Arrive Depart Arrive Depart Transfer time Transfer time Line B Arrive Stop time Depart Arrive Stop time Depart Driving time between stop Alighting time Waiting time Alighting time Waiting time Physical network Physical network

MODEL ACTIVITY LOCATIONS (supply) to Bagamoyo ± Activities Location Type Attractiveness to Morogoro Legend Dispensary Health center Hospital Low density (0-50 p/ha) Medium density (51-250 p/ha) High density (> 250 p/ha) Other urban Vacant/Agriculture Ocean & estuaries Arterial roads Rivers to Pugu to Kilwa 0 5 10 Kilometers

DATA COLLECTION: HEALTH SEEKING

LECTURE OVERVIEW Part 1: Theory 1. Health care as a social service 2. Accessibility concept Part 2: Example Dar es Salaam experience 1. Objectives of research 2. Collecting spatial and health seeking data 3. Health seeking behavior 4. Identify spatial inequalities (diagnosis) 5. Prioritize interventions (prescription

PROVIDER TYPE CHOICE

WHAT MOTIVATES CHOICE?

TRANSPORT MODE & TRAVEL TIME WALKING AND PUBLIC TRANSPORT ARE THE DOMINANT MODES 5 minute travel time intervals

LECTURE OVERVIEW Part 1: Theory 1. Health care as a social service 2. Accessibility concept Part 2: Example Dar es Salaam experience 1. Objectives of research 2. Collecting spatial and health seeking data 3. Health seeking behavior 4. Identify spatial inequalities (diagnosis) 5. Prioritize interventions (prescription)

ANALYZE EXISTING SITUATION (1)

LECTURE OVERVIEW Part 1: Theory 1. Health care as a social service 2. Accessibility concept Part 2: Example Dar es Salaam experience 1. Objectives of research 2. Collecting spatial and health seeking data 3. Heath seeking behavior 4. Identify spatial inequalities (diagnosis) 5. Prioritize interventions (prescription)

ANALYZE - PRIORITIZE - EVALUATE IMPACT Analyze existing situation - which areas are poorly serviced Prioritize interventions - what are best locations for new clinics Evaluate expected impacts how much will health system performance improve

BUILDING BLOCKS OF APPROACH

DISCUSSION & REFLECTION Strong points Firm theoretical, methodological and empirical foundation Sufficiently complete set of analytical instruments (add & close facilities + upgrade or downgrade service level) Weaker points No urban growth simulation (later done in separate research) Reliance on advanced GIS-based spatial analytical tools (complexity)

FURTHER READING Cromley, E. and Sarah L. Mc Lafferty 2 nd edition (2012) GIS and public health. The Guilford press. Joyce, K. (2009). To me it is just another tool to help understand the evidence : Public health decision-makers perceptions of the value of geographical information systems (GIS). Health and Place 15, p. 831-840. Higgs, G. (2004). A literature review of the use of GIS-based measures of access to health care services. Health services & outcomes research methodology 5: 119-139. Tanser, F.C. and D. le Sueur (2002). The application of geographical information systems to important public health problems in Africa. International Journal of Health Geographics.