Overview Introduction Health inequalities and accessibility Place-based measures of accessibility Time in place-based measures Discussion and conclusion What is accessibility? – Why does it matter?

Health inequalities are avoidable differences which result in poor health outcomes for the disadvantaged {Whitehead, 1992}. {London Health Observatory, 2008}

Geographical Health inequalities Geographical inequalities are differences in access to health due to distance or travel to health services. Intra-country: Differences between towns and cities Proximity and Optimal Service Location Access and Accessibility studies Location-allocation Geographical inequalities: Differences in access to health due to distance or travel to health services. Intra-country: (1) Differences between towns and (2) Proximity and Optimal Service Location Location-allocation Access and Accessibility studies

Spatial Health Accessibility Accessibility is the average opportunity for the user of a given area to participate in or use a health opportunity or service. Accessibility to health care is influenced by spatial and non-spatial factor. 21% of the LAC region lacks access to health care due to spatial barriers {PAHO, 2014}. distance, time, cost and ease of traveling to available services travel time and distance can create barriers to use {McLafferty, 2003 #176}. As a result, facilitating or improving accessibility to health care is a critical component in preserving and improving the health of a population. 21% approximately 107 million persons lack access due to spatial barriers. For comparison, 30%, 120 million persons lack access to health care for economic reasons.

Research objective Advance a new method of assessing the spatial accessibility of public health care suitable for use in developing country environments using Tobago as a study site.

Population-to-provider ratio Indicates accessibility as a ratio between supply and demand Widely used Requires little GIS expertise Intuitive and data is often readily available Supply – number of bed, number of nurses or number of doctors Demand – population of an area

- Good for gross comparisons of supply - Used to set minimal standards of supply by the WHO

Limitations Assumes there is no cross border flow No consideration of distance or travel impedance Ignores attraction and competition POINT 1: it only considers the population that resides in a given sub region POINT 2: short distances are handled the same as larger distance POINT 3: competition and attraction exists in the form of facility attractiveness or user choice Competition/attraction important because it affects demand and supply (capacity) Altogether gives an incomplete view of accessibility

Distance and travel Measures Use physical distance between origin and destination to derive a travel impediment which represents physical accessibility Travel mode, Travel costs and Euclidean, Manhattan or network distance/time

Easy to understand particularly network time {Apparicio, 2008}

Limitations Do not account for spatial distribution Does not account for attraction and competition Does not consider availability Distance and travel impedance alone are poor indicators of spatial accessibility Health service distribution influences utilisation, access and accessibility Depending on the choice of transit, some facilities may be easier to access. For example a facility at the border may require multiple stops compared to a facility closer to the user

Two step floating catchment area Two Step Floating Catchment Area (2SFCA) is an often used method that addresses the previous limitations. First step derives a catchment then calculates the population-provider ratios within the catchment. Second step sums the ratios at population points.

{Luo, 2003}

Limitations Assumes that services are always available at each provider Assumes that for all locations outside the catchment potential users have no access Only accounts for a single mode of transit

Spatial Accessibility & time Time affects a user’s choice set, modifying their possible options and thereby spatial accessibility. Accessibility is influenced by two factors: Availability:- opening and closing times of facilities, schedule of services Transportation choice:- car, taxi, bus

Integrating time Availability: 2SFCA assumes that services are available at all times. In limited resources situations, services are often scheduled e.g. weekly, bi-weekly, monthly Inclusion of health services schedule and facility opening and closing times.

Integrating time Transportation: Route choice is influenced by transit mode and time of travel/day. Catchment area may vary greatly based on time of travel particularly if users are using multiple modes of transit. Inclusion of traffic times into analysis.

Case Study: Tobago Responsibility for health care delivery is divided into 5 Regional Health Authorities. Study area, island of Tobago Population of 60, 000. Tobago has 1 hospital, 17 health centres and 5 outreach centres.

Regional Health Authorities of T&T Population: 60, 000 1 hospital 17 health centres 5 outreach centres (part time)

Tobago’s Public Health Facilities In 2012 a health needs assessment done for the island determined that despite the seemingly adequate geographical distribution of health faculties around the island, there were in fact many instances where communities were without adequate access to health care {Pierre, Bolastig and Mohammed, 2012}.

Analysis steps Create a network dataset which includes historical traffic data to better model travel times Generate an OD Cost Matrix using 30 minutes as the impedance.

  Typically use estimated time (Road distance * speed limit)

Analysis steps To better model availability: Each day is divided into two 4-hour periods, 8am- 12pm and 12pm – 4pm. Facilities that are not open during a period is removed from the analysis Facilities not offering the health service in question in a given period is removed

Analysis steps Since nurses provide a significant portion of the health care provision, they are included in the analysis. The presence of doctor increases the weight (supply and attraction) of a facility.

Original 2SFCA

Spatial accessibility: 1 week

Discussion The proposed method has three advantages: Supply is better modeled, accounting for nurses who provide the bulk of primary health care services Improved representation of availability of supply Catchment areas derived better reflects actual transit times

Discussion Including time in spatial accessibility assessments facilitates better understanding of how health services are available in space and time enabling health planners to better arrange and plan. The proposed method is flexible. Allows calculation of accessibility at different points in time Can be used to assess different types of health care

Conclusion Spatial accessibility barriers to health care prevent those who are disadvantaged from achieving the same health outcomes as those who are not disadvantaged. Addressing them is an important aspect of improving population health outcomes in the face of rising number of deaths due to Non Communicable Diseases and their heavy economic impact.

References Apparicio, Philippe, Mohamed Abdelmajid, Mylène Riva, and Richard Shearmur. 2008. "Comparing Alternative Approaches to Measuring the Geographical Accessibility of Urban Health Services: Distance Types and Aggregation-Error Issues." International Journal of Health Geographics 7 (1): 7-14. doi: 10.1186/1476-072X-7-7. Luo, W., and F. Wang. 2003. "Measures of Spatial Accessibility to Health Care in a GIS Environment: Synthesis and a Case Study in the Chicago Region." Environment and Planning B: Planning and Design 30 (6): 865-84. doi: 10.1068/b29120. London Health Observatory. 2008. "Health Inequalities." Accessed 17 December, 2015. http://www.lho.org.uk/LHO_Topics/National_Lead_Areas/HealthInequalitiesOverview.aspx#1. Pan American Health Organization (PAHO), and World Health Organization (WHO). 2014. "First-Ever Universal Health Coverage Day Urges “Health for All – Everywhere”." World Health Organization Accessed Feburary 7, 2016. http://www.paho.org/hq/index.php?option=com_content&view=article&id=10278&Itemid=192 6&lang=en. Pierre, Karen, Edwin Bolastig, Yoko Laurence, and Hamish Mohammed. 2012. Tobago Health Needs Assessment 2012.