Analyzing spatial disparities in access to health care: A methodology with application in Bangladesh

This paper develops a methodology for analyzing spatial disparities in access to health care in situations where the data base is limited, and applies it in the context of Bangladesh. The proposed indirect measures of inpatient and outpatient service utilization, and of quality of available services, seem to provide reasonably accurate, consistent, and interpretable results; these indices are combined into a composite index of relative access to health care. The form of the composite index and its components permits the incorporation of Sopher's disparity index into the methodology for measuring urban-rural disparities in relative access to health care. The empirical analysis based on subdivision level data revealed that Bangladesh's health care delivery system is, in general, characterized by extremely low level of access and a high degree of disparity in favor of urban areas, especially in terms of inpatient services. Spatial patterns of relative access and urban/rural disparity were perused through cartographic and statistical analyses; although clear-cut regional patterns did not emerge, the considerable spatial variations could be explained largely with reference to urbanization and density of population. Assuming improved level of access and minimal urban/rural disparity as basic policy goals a method to prioritize spatial units for future allocation of health sector resources is recommended.The author gratefully acknowledges the helpful comments on an earlier draft of this paper by Dr. S. M. Bhardwaj, Professor of Geography, Kent State University.     

A composed index of critical accessibility (CICA) to healthcare services in a traditional African City

While empirical works that analyse rural–urban differentials in accessibility to health services are common in the developing countries, systematic studies focusing on intra-urban variations in accessibility to overall healthcare resources remain scant. Yet, many urban dwellers especially in the Sub-Saharan Africa have to travel long distances within the urban space to access basic health services. This study employs composed index of critical accessibility (CICA) to analyse differentials in access to health resources in Ibadan, a traditional African City. Data on healthcare centre location, ownership, doctors’ population were collected through field survey while spatial data on the administrative units and populated places were obtained from archival sources. Also, data on road networks was collected. Results show that the distribution of health facilities across local administrative units varies. In terms health facilities, Ibadan South West has 26 (36 %) of the total number while Ibadan South east has only 7 (9.8 %). The Doctor-Population Ratio also exhibits similar variations as Ibadan North has 20.5 as against 2.2, 1.9 and 0.3 for Ibadan SW, Ibadan NW and Ibadan NE respectively. The CICA analysis shows that 228,938 inhabitants are in high risk of negative accessibility while 49,234 are faced with condition of low risk of negative accessibility, which implies that a significant proportion of the population still finds it difficult to access basic health services as and when needed. The variations in the distribution of this deprived population are also noteworthy as the largest proportion of this group was localized in Ibadan NW. This has grave implication for the health and wellbeing of the population and raises once again the question of spatial equity in the delivery of urban public service. Curiously, these differences in the level of accessibility cut across administrative boundaries which brings to the fore the role of jurisdictional partitioning in ensuring equity in the delivery of urban public services. This opens a vista of research opportunity into the role jurisdictional partitioning in service provision in the urban centres.     

International migration and health: Sickle cell and thalassaemia health care in the United Kingdom

Human migration has contributed to the redistribution of diseases from regions where they were endemic, thereby creating new areas where the task of control and management has become necessary. This is the case with respect to the major haemoglobinopathies — sickle cell anaemia and thalassaemia — in the United Kingdom since World War II. On the one hand, the great cultural diversity of the immigrant population presents an important challenge in delivering health care to the populations at risk of the diseases. On the other hand, the spatial concentration of these populations is one of the greatest advantages in the management of the disorders, since access to centrally located services can be optimized.The case of health care relating to the major haemoglobinopathies in the United Kingdom raises practical and theoretical questions about the most effective health care delivery models for ethnic minority needs. In turn, this issue has important implications for decisions concerning national and regional budgetary priorities in the health service and the position of minority medicine in the allocation of resources.     

Determinants of utilisation of health services by women in rural and urban areas in Ghana

The paper examines the factors that influence the utilisation of health services by women in the rural and urban areas in Ghana. The systematic sampling procedure was used to draw the sample from women aged 18 and above with diverse backgrounds from Ahafo-Ano South district, representing the rural districts and Kumasi metropolis, representing the urban districts. The research instruments used for data collection were the questionnaire and formal interviews. Multiple regression was the main tool for analysis. The research reveals that the key factors that impact significantly on the utilisation of health services by women in the Ahafo-Ano South district are, distance, income and family size (number of children) while for Kumasi metropolis they are education, distance and marital status. Whereas it is clear that distance is a common problem facing women in both rural and urban areas in Ghana in the utilisation of health services, marital status and number of children have emerged as contrasting factors influencing utilisation of health services by women in rural and urban Ghana. Recommendations to improve utilisation include the location of maternal and child health services within easy reach in the rural areas, intensification of family planning education in the rural areas, the empowerment of women through access to formal education and vocational training for income generation activities and the full implementation of the National Health Insurance Scheme (NHIS). A model of utilisation of health services by women in the rural and urban areas has emerged.     

Energy and policy providing for sustainable rural livelihoods in remote locations – The case of Cuba

Modern, small-scale renewable energy technology has the potential to enable and sustain rural livelihoods, particularly in developing countries remote locations without access to the grid. Yet, the provision of rural energy to isolated communities might not achieve the desired long-term result unless its development is part of wider national policy geared to sustainable development and social equity. This article shows how a combination of technology and policy targeted at the improvement of livelihoods in rural areas is the best solution for maximising the capacity of renewable energy to deliver services. It pinpoints the transforming processes and the institutions participating in the delivery of energy technology. This work draws on the Cuban experience of renewable energy technology, that country’s efforts to improve quality of life for remote populations, and its pledge to promote environmental sustainability. Using a sustainable livelihoods approach, the results of a survey in a rural community are analysed in the framework of existing assets and policies. The article describes how it is not only local users who benefit from a comprehensive technical, social and environmental energy approach. The same governmental administration that promotes such services has much to gain from technology that works well, benefits the poor in remote locations and protects the environment within its larger policy promoting sustainable and egalitarian society.     

Quantitative indices for medical & personnel facilities

The status of medical facilities and personnel in the Kingdom of Saudi Arabia, at the end of the fourth five-year plan (1985–1990) was reviewed and analyzed regarding the standards of services and workload of health personnel for the different regions and urban/rural areas in the Kingdom. Innovative indices for the quantitative analysis of medical facilities were developed. The analysis of health facilities in Saudi Arabia shows that the Kingdom enjoys a high standard of medical facilities. However, there are maldistribution of clinical resources and personnel between regions and between urban/rural areas. Utilization of these indices for the reallocation of medical facilities and personnel to ensure even distribution of services for all inhabitants of the Kingdom was illustrated. In addition, indices give a guideline for the future planning and the rate of increase of these facilities that keeps the standard of medical services in the proper class desired with minimum resources wastage.     

Private non-degree practitioners and spatial access to out-patient care in rural India

Most rural areas in the developing countries lack access to qualified out-patient (OPD) care. The gap in health services provision arises, due to lack of qualified doctors and is oftentimes filled by unqualified doctors who are also known as private non-degree practitioners (PNDPs). Despite their dominance, their presence is often neglected in access to health care studies. This leaves a scenario which lacks informal, but predominant, care. This paper uses a mix-method approach, combining exhaustive quantitative census of all health care providers along with location details in Geographic Information System to address the accessibility to PNDP. Longitudinal quantitative as well as spatial surveys were conducted for 3 years (2010, 2012 and 2013) in districts of Pratapgarh and Kanpur Dehat in state of Uttar Pradesh and Vaishali in Bihar state. The results of this study show that PNDPs account for 25 % of the all health care providers active across the study areas. The PNDPs are active in a radius of 2–5 km and are main workforce for the OPD care. Considering all health care providers PNDPs provide best potential accessibility to OPD care. If the PNDPs are removed from the scenario; remote areas will be the most affected ones, leaving them with almost no OPD care.     

Need for and access to supportive services in the child welfare system

The purpose of this paper is to examine how geographical availability of social services is related to foster care entry rates and referrals for child maltreatment investigations. The primary concerns are to (1) determine locations across Los Angeles County where the availability of social services is low but display a high need for those services and (2) begin to examine how the geographic distribution of social services is related to rates of referrals and foster care entries in child maltreatment. Archival data for all 288 zip codes within Los Angeles County were collected on rates of referrals, foster care entries, location and types of social service agencies, and zip code demographics. Data were analyzed using point process models and spatial regressions. Higher densities of child welfare services in local areas (for referrals) and lagged areas (for referrals and foster care entries) were related to lower rates of child maltreatment. The density of housing and housing-related services was negatively related to referrals in local areas and foster care entry rates in lagged areas. Areas with higher densities of substance abuse and domestic violence service agencies had significantly higher rates of both Child Protective Services referrals and entries into foster care in local areas. While the total density of child welfare services within and surrounding zip code areas is related to lower rates of referrals and foster care entries, the findings are less clear about what those specific services are. Living in and around “resource rich” zip codes may reduce rates of child maltreatment.     

Modelling the effect of deprived physical urban environments on academic performance in the Philippines

This study investigates how physical urban environments affect academic performance of urban public elementary schools in the Philippines by analysing the physical environment of school facilities and slum areas. Global, local, and semi-parametric regression analyses indicate that there is disproportionate provision of resources among the government schools and that lower academic performance is associated with the provision of fewer clinics rather than the proximity to poverty hotspots. Semiparametric, geographically weighted regression modelling outperformed global and local modelling, and estimated up to 30 % of the variation in math scores where the semi-parametric regression model is based on each school’s number of teachers and rooms, building conditions, availability of health clinics, and the location of slum areas near the school. On the basis of the research findings, it is concluded that the current state of school buildings is adequate and is a lower priority than the provision of health care support and smaller pupil–teacher ratios. Hence, government programs that aim to enhance the academic performance of children from the deprived physical urban environments should prioritize the provision of health clinics as well as maintaining few large schools with small pupil–teacher ratios.     

Public policy and residential provision for the elderly

In recent years there has been a growing concern about the best type of residential care for the increasing elderly population in Britain. This paper examines the response of the public, private and voluntary sectors to the provision of residential care. It looks at the relative levels, spatial variations in the levels and changes in the proportions of provision by each of these sectors for the years 1981 and 1984. The levels of provision are related to indices of need, available resources and the political disposition of each local authority area. This paper then focuses on the variations in the growth of the private-sector provision of residential homes. It was found that the metropolitan districts had the greatest proportion of voluntary-sector provision; and the traditional seaside retirement counties such as Devon and Lancashire had the highest levels of and experienced the greatest growth in private residential care. The key variables in explaining variations in the mix of provision between areas were indices of need and resources. This study has established that there are great regional variations in the mix of the different sectors of residential care, although it is not possible to offer a total explanation of these differentials. In Britain, there are substantial inequalities in terms of the choice of types of provision for the elderly population which have significant implications for local authority policy.     

Voluntarism,defensive localism and spaces of resistance to health care restructuring

This paper examines the evolving role of volunteers and the voluntary sector in shaping community responses to structural change in health care systems. It contributes to the emerging understanding of the different forms voluntarism can take within and among places, including as a space of resistance to contemporary restructuring initiatives such as regionalization. Within the geographies of voluntarism literature, however, little attention has been directed towards interrogating the local dynamics of such voluntarism, especially as it is reflected in public discourse. We address this deficiency through a media-based case study of public reaction to the recent implementation of Ontario’s Local Health Integration Networks (a type of regional health authority). Specifically, we examine a decade of newspaper coverage in a mid-size Canadian city region to document and characterize how the activities of volunteers and voluntary sector organizations in the community are portrayed in light of the structural imperatives to integrate health care services and regionalize health care governance. The media findings reveal a suite of public concerns and related activities, with the voluntary sector called upon in various ways to defend the autonomy of the community against the perceived threats to local services, employment and vulnerable populations. We interpret the evident complexity of voluntary sector resistance as a form of ‘defensive localism’ and discuss implications for developing informed policy on health care restructuring and for advancing knowledge on the local geographies of voluntarism.     

[Without Title]

The paper examines the factors that influence the utilisation of health services by women in the rural and urban areas in Ghana. The systematic sampling procedure was used to draw the sample from women aged 18 and above with diverse backgrounds from Ahafo-Ano South district, representing the rural districts and Kumasi metropolis, representing the urban districts. The research instruments used for data collection were the questionnaire and formal interviews. Multiple regression was the main tool for analysis. The research reveals that the key factors that impact significantly on the utilisation of health services by women in the Ahafo-Ano South district are, distance, income and family size (number of children) while for Kumasi metropolis they are education, distance and marital status. Whereas it is clear that distance is a common problem facing women in both rural and urban areas in Ghana in the utilisation of health services, marital status and number of children have emerged as contrasting factors influencing utilisation of health services by women in rural and urban Ghana. Recommendations to improve utilisation include the location of maternal and child health services within easy reach in the rural areas, intensification of family planning education in the rural areas, the empowerment of women through access to formal education and vocational training for income generation activities and the full implementation of the National Health Insurance Scheme (NHIS). A model of utilisation of health services by women in the rural and urban areas has emerged.     

Marine Ecosystem—Based Management: Definition,Principles, Framework and Practice

As the largest ecosystems of the earth, marine ecosystem provides many types of ecosystem service to human. More than 60% of the global population lives the coastal area. A healthy ocean is critical to our economy, health and way of life. However, with rapid population growth and densely inhabited coastal areas, our dependence on marine resources is greater than ever. The overuse and mismanagement of ecosystem services have placed great pressure on marine systems, thereby threatening the future of marine ecosystems, and the services they provide. With anthropogenic pressures increasing in coastal cities, adopting ecosystem-based management frameworks that minimize impacts on marine environments while allowing for sustainable development is critical. Marine Ecosystem-Based Management seeks to manage marine resources in ways that protect ecosystem health while providing the ecosystem services needed by people. Rather than focusing solely on a single species or resource, MEBM incorporates science and balances the demands of user groups in a manner that produces management strategies that are more likely to be sustainable than traditional approaches. The definition, principles and framework were discussed in this paper based on the summary of literature, and two examples were introduced. Last, some suggestions were put forward to marine ecosystem management for ocean ecosystem and for healthy coastal resources sustainable utilization.     

Distance as a predominant factor in the utilisation of health services in the Kumasi metropolis, Ghana

The research primarily aims at testing a model, adapted from existing models, on the influence of distance on the use of health services in the Kumasi metropolis, an expanding urban centre in Ghana. Primary data, collected between August 2000 and February 2001, were used for the study. The data were analysed using a multiple regression model and compound bar graphs. A sample of 250, drawn through systematic random and stratified procedures, was used for the cross-sectional retrospective survey. Data were collected through formal interview schedules, after preliminary observational survey. The survey has established three principal findings. First, distance shows a strong inverse relationship with the utilisation of health services in the metropolis. Second, travel time and transport cost, variables that are related to distance, exhibit a weak negative and positive associations respectively with the use of health services. Third, the vulnerable groups of women, the aged, the sickly, the illiterate and the poor are not affected by distance decay in the utilisation of health services. Finally, independent variables that are statistically significant in influencing utilisation, alongside distance, are education, service cost, quality of service and health status. Recommendations for locational modelling of health services at the deprived periphery, an introduction of an insurance scheme to facilitate health care use, and recommendations for further research have been made.     

“Functional localities: an integrated spatial approach towards health care locality definition”

This paper demonstrates a spatial approach towards the definition of localities for health care planning. Recent international decentralisation of health care provision, and more specifically devolution within the United Kingdom, emphasises the need to develop a geographical focus in the delimitation of local structures for health care planning. Geographers, but most especially those applying Geographical Information Science (GIS) techniques, have made enormous contributions in this field and more generally in research related to health services. This paper considers some of these previous approaches and moves on in the light of new technologies, and more importantly the availability of appropriate data, to create localities that reflect dynamic spaces of social interaction, administration and policy. The paper’s focus is placed on the importance of flow data that reflects␣the spatial interaction between services and the population. This data, divided into three sub-groups of administration, education and health, allows us to identify the population’s allegiance to place and ultimately create spatially bounded functional localities that reflect this. Whilst the approach is largely technology driven, it also incorporates the expertise of local health care professionals thus recognising the importance of collaboration and multi-sectoral engagement. Although this combined approach impacted upon the way in which the final localities were defined, crucially it enabled us to incorporate features of both rigorous spatial analysis and a wealth of local knowledge.     

Placing voluntarism within evolving spaces of care in ageing rural communities

Guided by a theorisation of voluntarism as a critical process shaping local outcomes of changes underway in health care systems and in rural communities, this paper re-analyses qualitative results from previous case studies of rural ageing to deconstruct the multifaceted role of the voluntary sector in facilitating the emergence of homes and communities as ‘new’ spaces of care. The specific focus is on the lived experience of voluntary sector care providers from the perspectives of non-profit organisations, community groups and families as well as elderly residents of rural communities in Canada and New Zealand. The findings confirm the local dynamics of voluntarism as a crucial yet neglected component of sustainable rural services and communities. More importantly, they reveal the voluntary sector as a major source of resistance to both the short-term changes mandated by restructuring and longer-term changes associated with rural ageing and service decline. It is through resistance that voluntary organisations and volunteers are seen to be engaging most intensely with the challenge of ageing in place within evolving spaces of care. A more nuanced understanding of their complex role is a prerequisite for developing informed policy on rural ageing and care provisioning.     

Which households are most distant from health centers in rural China? Evidence from a GIS network analysis

In this paper we have two objectives—one empirical; one methodological. Although China’s leaders are beginning to pay attention to health care in rural China, there are still concerns about access to health services. To examine this issue, we use measures of travel distances to health services to examine the nature of coverage in Shaanxi Province, our case study. The mean distance by road to the nearest health center is still more than 6 km. When we use thresholds for access of 5 and 10 km we find that more than 40 (15) percent of the rural population lives outside of these 5 (10) kilometer service areas for health centers. The nature of the access differs by geographical region and demographic composition of the household. The methodological contribution of our paper originates from a key feature of our analysis in which we use Geographic Information System (GIS) network analysis methods to measure traveling distance along the road network. We compare these measures to straight-line distance measures. Road distances (produced by network analysis) produce measures (using means) that are nearly twice as great as straight-line distances. Moreover, the errors in the measures (that is, the difference between road distances and straight-line distances) are not random. Therefore, traditional econometric methods of ameliorating the effects of measurement errors, such as instrument variables regression, will not produce consistent results when used with straight-line distances.     

Social and environmental regulation in rural China: bringing the changing role of local government into focus

China’s rapid economic growth following the 1978 reforms has resulted in significant economic, social and environmental change. These reforms and their outcomes have been subjected to considerable scrutiny. However, relatively little research has been directed towards the relationship between the changing role of local government, which has itself been subject to substantial restructuring, and the local mediation of the social and environmental impacts of rapid economic growth. This paper investigates the local manifestation of social and environmental change in Zhejiang Province. In particular, it considers the changing role of local government in the regulatory process, and features a case study of Huzhou Municipality. A synthesis of the factual knowledge and perceptions of 48 key-informants from government and public institutions and rural industries is used as the platform for an analysis of the changing nature of local regulation with respect to the provision of key public services (health care and education) and environmental protection (water pollution control). The results reveal the ability of local government to selectively implement national and provincial policies in light of local priorities, which is taken as indicative of the emergence of local agency within local development processes. The case study suggests a need to re-evaluate conventional wisdom on the absence of autonomy at local levels of government in China, particularly as it relates to the continued devolution of administrative responsibility and the emergence of increasingly powerful economic interests.     

The determinants of primary health care utilization: a comparison of three rural clinics in Southern Honduras

Primary health care utilization is poorly understood in many parts of the developing world. This is especially true in rural places, such as Santa Lucia, Intibuca, Honduras, where there are only three primary health care facilities servicing almost 12,000 people, and generally speaking access to care is limited. This study examines the factors that can be used to explain primary health care utilization, and aims to improve the understanding of patient utilization behavior. A better understanding of utilization can be used by health service planners to improve primary health care delivery in this and similar locations. The findings of this research indicate that utilization can be explained, to a large extent, by factors relating to economic status and walking time to clinic. These findings are consistent with findings from prior research. In addition, a home territory variable is used to examine spatial variations of utilization behavior. This variable has not been considered in previous utilization research, and is found to be a very significant determinant of health facility utilization in the study area.