Abstract
Good access to health services in developing countries can be important for effective treatment amongst the population, thus preventing unnecessary death in the community. Primary care is pinpointed as the most essential form of healthcare for managing population health because it is the pillar of health care delivery to persons in developing countries. It is approximately low-priced which can be more easily conveyed than any distinctive feature and inpatient care, and if correctly apportioned it is most cogent in avoiding disease advancement on a large scale. This review discusses recent literature on GIS and health care it explains the use of GIS-Based approach in measuring the accessibility of primary health care, describes recent developments in GIS and factors influencing the access to health services in developing countries which can be spatial and non spatial factors, but much emphasises was laid on the spatial factors which is distance and geographic location.
Keywords Geographical information systems, accessibility, primary health care, distance.
1. Introduction
Human health and well being have a long history and a paramount goal in the mind of every government- a key to economical, political, stability and growth of a country. Geographic information systems (GIS) and other spatial analysis methods give such a fantastic solution in data analysis and thus play a major role in morbidity and mortality control. GIS is multidisciplinary, broad topics in geography, computer science, statistics, cartography and other subject- specific fields. The application of GIS to the health field is new but growing fast. Another important factor affecting a large array of health outcomes is proximity to care. Distance to facility has been associated with increasing maternal and infant mortality, decreased vaccination coverage, increased adverse pregnancy outcomes, and decreased contraceptive use [1-5]. One of the most important forms of health care for maintaining population health is primary health care because it is cost effective and can be delivered more easily and is effective in preventing disease.
Quick accessibility to GPs, health care and services is an imperative tool to good health, physical, spiritual and emotional well being. While significant progress has been made on several fronts in checking morbidity and mortality in recent years, research findings have not always been readily translated to better policies and programs for creating healthy conditions. Numerous authors has reviewed the application of geographical information systems to health and epidemiology [6-15] although found below the potential use an agreement has been reached that GIS has much to provide to health services. In developing countries, community based primary health care(PHC) is the pillar of health care delivery to people, the success of this health care is the accessibility to majority of the population. Poorer population probably might use the nearest health care facilities irrespective of inconsistency in the standard of delivery. Although to a larger scale more research has been conducted with GIS- based approach in majority of field in health related topics but much has not been researched to the impact on morbidity and mortality rate across developing countries and the world at large. The aim of this paper is to review the use of GIS: a technology for integrating, manipulating, editing, imputing, analysing, visualizing and managing geographically referenced information (data) in assessing primary health care in developing countries. Primary health care is not based only on treatment of diseases but also it focuses on improving the overall health of the population in the community. The principles of primary health care is based on some mainstays which include entirety, good characteristics such as being socially and culturally acceptable with standards that meets up with the scientific and clinical practice, impartiality (no one should be denied access to health services), effectiveness and enough resources to finance and control the basic set of services. Accessibility to good health services is believed to reduce or remove the risk of morbidity and mortality to human life as long as there is ready access to treatment which can help to curb the eliminating effects. To evaluate this research area, some studies will be carried out using substitute fickles, like distance to major road or traffic degree.
GIS is a tool of great indigenous potential for health in developing countries as health is largely determined by environmental factors (those determinants of disease that are not transmittedgenetically). GIS with some of its broad applications is applicable to understanding the spatial variance in morbidity and mortality and its relationship to primary health care. GIS has been used in variety of ways in health sectors like its application to emergency planning and ambulance routing, analysing the potential impacts of noxious facilities on trends in morbidity and mortality in local neighbourhoods, and its use in weighing health care in poor countries. [16-17]. This review emphasizes the current status of techniques used in assessing primary health care in developing countries with the use of the latest software, GIS. Knowledge and understanding of population distribution and primary health care services are important in the allocation and planning of health care resources. Informed decisions concerning resource allocation is dependent on good health system management. In the absence of data, this decisions may be impaired, but with GIS, the analysis of resource pattern is an area it can contribute significantly through its ability to analyse multiple layered dataset from carried sources with different scale using one of its extension to provide qualitative result that can aid in decision making processes of the stakeholder of health care services.
In this paper, I review the measures of accessibility, use of GIS in measuring accessibility of PHC in developing countries and Contributing factors and specific improvement to integrate GIS capabilities in presenting ideal measures of accessibility to health services. I also looked at previous studies which have developed GIS-based approach that permits analysis of distance travel time based measures to compute accessibilities in these countries. The use of GIS in understanding the health outcomes and management ability in the current research in the relationship measures and health outcome were highlighted for further research in relation to new development in the use of GIS for accessibility to health care delivery in developing countries. Health care research and management usually falls into three categories using a GIS approach, these categories are:
Measuring access to health care services.
Understanding the utilization pattern of the available health services.
The design, application, and implementation of the health services.
Expediting the spatial attachment of contrary health, social, and environmental datasets is a significant role in GIS for measuring health care needs. Researchers now make use of the analytic capabilities to relate data sets that rely on nonconsistent areal units and to generate meaningful service areas even though the layering capabilities of GIS have been used for many years [18-19]. Health needs data is integrated in GIS-based decision support tools which allow communities and decision-makers to criticize questions of health care needs, access, and availability as digital information on morbidity, demographics, and utilization becomes more widely available.
2. Measures of Accessibility to Primary Health Care in Developing Countries
Accessibility to health care can be classified into two: which is the revealed accessibility and the potential accessibility. The revealed accessibility is based on the actual use of health care services while the potential lays more emphasizes on the geographic patterns and supply of medical resources. The geographic patterns include both spatial factors (distance and geographic location) and non spatial factors (income, age social class, sex etc) [20-22] and their mutual action can influence one’s access to health care. [23] Further divided each factor into spatial and non spatial accessibility. In this paper I focused on the spatial accessibility. Measures of accessibility to health care can be either area-based or distance-based. Area-based measures describe for areas like counties, towns, or states, the ratio of population need to services available. Measures like the general practitioners to population ratio have long been used to describe geographical disparities in access to General practitioners across developing countries [24]. GIS is well used to measure spatial accessibility to health care because they contain the major components needed for the analysis which are:
Data capture storage, management and manipulation tools for both spatial and attribute (textual) data
Core analysis algorithms such as buffering, overlay, proximity analysis, shortest path and raster cost-distance analysis
Programming environments to customize and extend existing algorithms and create new analysis tools
Mapping and visualization tools to communicate the results of analysis
2.1 Role of Distance
The application of distance and utility to health care has not yet been explored as distance is an important feature of health service use. Distance focus on travel time or cost between the population and health service providers. The most used measure is straight-line or Euclidean distance. A distance from the elderly population to hospital-based geriatric services was computed using Euclidean distance in GIS [25]. By examining the frequency distribution of distances, the he identified elderly populations with poor access to geriatric services. Euclidean distance is imperfect because of its failure to incorporate the ease, cost and time of travel, and access to transportation as a measure of geographical access [26]. More reliable measures of geographical separation can be created with the aid of GIS by combining spatial information on roads, transportation, and population. Access to primary health care was studied in Bolivia to capture the difficulties of travel in a mountainous region [27]. Many studies have used GIS to calculate network distances and travel times based on road type and quality to assess travel along transportation networks [28-32].
Addition of transportation makes the measurement of geographical access complex. A mix of people relies on different modes of transportation in a given area and this makes the levels of geographical access vary [26]. Access to general practitioner services in East Anglia (England), an area where travel by both bus and car is common was analysed [33]. They found the population in the area where deprived by high health care need and low transportation mobility, and these areas were targeted for bus service improvements.
The findings of Martins et al.[34], on the factors that influence the uptake of Renal Replacement Therapy (RRT) using multilevel modelling and used GIS to calculate catchment areas and travel distances suggested that deprivation, access and supply characteristics significantly influence acceptance rates but there are also important regional influences. Tanser et al [35] used distance usage index (DUI) for an overall measure of clinic usage (sum of distance from clinic to public homestead divided by the sum distance from clinic to all homestead within distance – defined catchment area and concluded that if DUI is greater than 100% it shows that the clinic has a good attendance within its own distance catchment and does with DUI less than 100% has a poor attendance within its own distance catchment. Noor et al [36] defined equity in physical access to clinical services with a focus on malaria planning and monitoring in Kenya and discovered that people in rural communities travelled more distance to health facilities than those in urban areas. A recent study used travel time to estimate actual times taken for patients to reach their nearest hospital but the use of straight- line distances were equally reliable in the approximation of such reported times. [37].
2.2 The Use of GIS in Measuring Accessibility to primary health care
GIS as a widespread software for various purpose, application and implementation has been used in various health issues, for measuring accessibility, correlation distribution, spatial accuracy of health data and utilization of health services. [16] talked about the use of GIS in health for a couple of years and the use of standard GIS functionality in measuring accessibility. Frank Tanser has written quite handful publications on malaria, tuberculosis and HIV/AIDS in Africa. Example of some of his work is the use of GIS to calculate the accessibility of patients to health services. [38, 39, 40 &35] Used GIS to document the decrease in distance to the nearest tuberculosis directly observed treatment (DOT) dissemination point, to quantify the relationship between road accessibility and HIV prevalence, to calculate population to clinic bed ratios and to spatially analyse clinic use patterns. [41] Used GIS to access and optimize ambulance response performance. [42] Used one-way travel time from the subject's street level geocoded residential location to the street level geocoded primary practice location of the temporally closest provider. Table 1 provides a summary of the definitions for the alternative measures of geographical access.
Table 1: Alternative measurements for accessibility
Method
Units
Definition
Rural - urban residence
providers per capita
0 or 1
ratio
Country of residence designated as an MSA (Metropolitan Statistical Area)
Number of providers in country divided by population
Zip-to- Zip Euclidean Distance
Miles
Euclidean distance to closest zip code geocoded provider
Euclidean Distance
Miles
Euclidean distance to closest street geocoded provider
Road Distance
Miles
Travel distance along shortest route to closest provider
Travel Time
Minutes
Travel time along quickest route to closest provider
Some researchers complained that the degree of distance from hospital was associated with lower probability of admission for discretionary conditions[43, 44]. In south Africa, [35, 45-48] used GIS for various research and it yielded positive results for example to model and understand primary health care accessibility in rural south Africa, analyse health care pattern usage optimise location of new health care services and a whole lot which suggest a great potential for utilization of health care services when there is increase in physical accessibility.
3. Discussion
Many studies have measured accessibility in developing countries based on the population datasets of patients to availability of health services which are integrated into GIS to assess the distance – travel time relationship [38, 46, 49, 50, 51 & 52]. These measurements where based on nearness of health services, road networks etc. A major premise in many of the research conducted declared a near neighbour approach of patient utilising the nearest health facilities due to distance-time obstruction thereby creating a large bunch of point around that particular facilities, an example is using post coded patient registers and calculated travel times from postcodes to GP surgeries, only 56% of the population were registered with the closest GP and the proportion registered with the closest practice varied between urban and rural areas [54].
Impingement of access over health care in respect to the associating factors that impedes patient in getting services can also be checked using GIS. Although it might not have gained a wider popularity among developing countries but to the western world its application is unstoppable. An example was applied in Chicago, [53] gravity model to measure better geographical accessibility, since inequitable geographic distribution of health care resources has been recognized as one of the problems in the united states which states that measuring a simple ratio of supply to demand in an area or distance closest to provider are easy to measure spatial accessibility. GIS was used to calculate the potential access for the elderly to 214 hospitals in Illinois [25], they originated alternative measures of accessibility based on straight-line distances to the closest five hospitals for each census block group in order to set up if there were variations in accessibility between those living in Metropolitan and rural areas.GIS can be used to measure urban Poverty which is a key factor in data inconsistent in Africa using spatially related life quality indicators in terms of income level like graphics and statistics to weight. The use of GIS in developing countries is gaining strength as areas of errors in data is been critically looked at and can be used to locate new health care centres, plan the transportation network for quick accessibility to health care, correlate the percentage of GPs to identify possible low count of personnel and for decision policy management, an example of this is using GIS to create continuous density surface of primary care providers for children [50].
Transformation in GIS-based accessibility measures can be used to monitor the impacts of health sector reforms, for example [55] used GIS to find improvements in access to outpatient care following health care reforms and concluded suggesting that GIS has great potential to identify those communities that have inadequate access to health care and where it could be corrected to improve access. GIS also permits analyst to analyze the impact of access in relation to combined factors such as patient characteristics and rurality, an example of this was in an area of British Columbia in Canada where rates of hospitalization was examined and found that there was a contrary contingency between such rates and physical distance to hospitals [56]. GIS was used to also analyse access to hospice care in North West England, they calculated measures of potential accessibility in relation to deprivation scores using the combination of distance and travel time methods to highlight lapses in provision and demonstrate the use of such tools in planning hospice [57]. A recent research in the United Kingdom has taken heed on the need to consider the elaborateness of the transport system on the analysis of accessibility measures based on both car driving times and public transport timetables [26, 33 &58]. GIS is greatly being used in developing countries in order to analyze potential access to health facilities and to plan the location of new treatment centres, some examples are [36,59] access to treating malaria, [38] tuberculosis, [39] access to HIV treatment, [60, 61, 62] planning public mental health and cancer resources, [63] to analyze attendance pattern in rural clinics. GIS was used to identify the returning response of locating new clinic in Hlabisa health district to achieve maximum population- level increase in primary health care accessibility [35].
Accessibility can be altered by cultural and social factors (knowledge and information), by economic factors as the use of different forms transport and access to channels of communication are often associated with fascinating commercial cost [64].[65-67] studied several social factors affecting choice and use of health services in developing countries which includes quality of care, perceived level of sickness, transport availability, income, relationships to health facility staff, religion, occupational status and concurrence of relatives to health facilities. These factors are difficult to measure and vary from household to household despite the fact that social factors are important determinants of health service usage. Improvements in health care use can be instantly accomplished by the simple measure of transposing health centres or improving the road network [68]. The siting of new facilities and resource allocation can be updated by the identification of deficiencies in the coverage and of exposed populations with limited access to care [20]. Developing geographical access to primary health care can have direct application on enhancing health outcomes [27]. Even with the many successful uses of GIS applications for health care research and planning, GIS remains a significantly powerful but under-utilized analytical tool in developing countries, it is being applied more often to answers complex problems and inform optimal resource allocation [69]. GIS has been used to study sequence of diseases (such as identifying leukaemia clusters), spatio-temporal changes in health outcomes, and identifying possible causes of the disease (like the relationship between cancer rate and diverse environmental factors). These primarily involve the connection of health information with environmental and socio-economic data. [70] Also used GIS to aim the resources for avoiding disease by giving prominence to areas with extremely high rates, and to presage which areas might be dangerous in future and which may avail most from future local population screening. GIS was used to carry a research in the UK at the West Midlands Cancer Intelligence Unit and the Small Area Health Statistics Unit (SAHSU) [71] which is an example of health outcomes and epidemiology application, another example is [72] in North East England used GIS to investigate the association between asthma rate and the nearness to industrial sites and suggested relationships with common wind patterns. [73] Delineated the application of GIS in modelling drug abuse, common methods for assessing the rate, dominance, and spread of drug abuse tend to be backward looking and are not competent of predicting spatio-temporal trends. They also established a GIS drug abuse system to build an active model for predicting and publishing spatio-temporal trends and connecting environment with behaviour. It includes a series of parameters to model drug abuse and its geographic spread across a population using UK data as a background for establishing a European-wide predicting system. Their suggestion provides the background for investigating more complex geographic wide distribution scenarios such as the introducing new practices by new users, effects of tourism and migration, the establishment of education and restorative initiatives, drug transportation, cross-border contact, and booming favourable circumstances for economic and international contact.
The use of GIS in health care research has expanded in an impressive manner in the past years. Some researchers continue to view GIS as basically a mapping tool even though GIS has indulged new ways to inquire health care needs for small geographical areas, better measures of geographical access to health services, and new approaches to analyzing and planning services locations. Research of health services demands spatial data on health resources, population, utilization, treatments, and outcomes, and data are often nonexistence or given at different temporal and spatial scales. The acceptance of GIS has been very disproportionate in health services a result of structural obstacles. There is less research on the impact of the measures of health outcomes in developing countries; therefore more research is needed in the use of GIS to analyze the impact of these outcomes and the distribution of health care facilities in developing countries.
4. Conclusion
This paper is about the review of previous approaches to measure accessibility of primary health care in developing countries with the use of geographical information systems. These have shown that distance is the major problem encountered in most of these countries due to the population datasets of patients to availability of health services. It is inspired to deal with the public as one of the main recipients of any national spatial health information infrastructure and they should be granted full access to data and information because GIS can help to build up healthy behaviours by registering where the populations are located that have the greatest need of refined information, then using GIS-enabled Internet sites as an outreach vehicle for community health education [74]. Numerous authors has worked on the accessibility of primary health care in developing countries and they had different methods in measuring the accessibility and also considered different things [38, 39, 40 &35] Used GIS to document the decrease in distance to the nearest tuberculosis directly observed treatment (DOT) dissemination point, to quantify the relationship between road accessibility and HIV prevalence, to calculate population to clinic bed ratios and to spatially analyse clinic use patterns. [25] Also used GIS to calculate the distance from the elderly population to hospital based geriatric.
When GIS is properly used from a community approach, it could possibly act as an effective proof- based practice tool for early problem discovery and solving. It can help in planning and adjusting clinically and cost effective actions, predicting actions before making any financial commitments and imputing precedence in a climate of finite resources; alter practices; and steadily guides and examines alterations, inform and educate as well as guard events. Access to more complex diagnostics and series of treatment operated by formal health services to control diseases, where microscopy and second-line drugs are regulated and not provided outside of primary health care or in community-based approaches to malaria management is mostly restricted by distance. Deferment in decisions to seek care, timely arrival at appropriate diagnostic and treatment services and the receipt of enough care from service providers are the consequences of any disease. This review as drawn attention on various use of GIS, limitations and also has outlined some areas for further research of primary health care in developing countries. The worldwide flow towards faster, more effective computers, nature of developing countries disease stress and deficiency of trustworthy disease statistics makes it a reasonable, appropriate and effective technology for health research in developing countries. GIS hold an important hope for health research and growth in developing countries regardless of any impediments. The initiation of GPS and remote sensing will help to improve the accessibility to primary health care in developing countries.
