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Background: Surgical care is increasingly recognised as an important component of global health delivery. However, there are still major gaps in knowledge related to access to surgical care in low-income countries. In this study, we compare distances travelled by surgical patients with patients seeking other medical services at a first-level hospital in rural Mozambique. Methods: Data were collected on all inpatients at Hospital Rural de Chókwè in rural Mozambique between 20 June 2012 and 3 August 2012. Euclidean distances travelled by surgical versus non-surgical patients using coordinates of each patient’s city of residence were compared. Data were analysed using ArcGIS 10 and STATA. Results: In total, 500 patients were included. Almost one-half (47.6%) lived in the city where the hospital is based. By hospital ward, the majority (62.0%) of maternity patients came from within the hospital’s city compared with only 35.2% of surgical patients. The average distance travelled was longest for surgical patients (42 km) compared with an average of 17 km for patients on all other wards. Conclusions: Patients seeking surgical care at this first-level hospital travel farther than patients seeking other services. While other patients may have access to at community clinics, surgical patients depend more heavily on the services available at first-level hospitals.
Data for this study were collected from the Hospital Rural de Chókwè (HRC) in the district of Chókwè in Mozambique. Mozambique is a country of approximately 25 million people located in southeastern Africa.15 The average life expectancy in 2012 was 49.9 years and over one-half (52%) of its population is <18 years old.15 The 2010 adjusted maternal mortality ratio was 490 deaths per 100 000 live births, slightly lower than the average for sub-Saharan Africa (500 deaths/100 000 live births), but much higher than the worldwide average of 210 deaths/100 000 live births.15 A little over one-half of women have institutional deliveries (55%) and the Caesarean section rate is <4%.15 HIV is a significant public health problem, with an estimated prevalence at 11.1% in 2012.15 In 2012, Mozambique ranked 185 out of 186 countries on the Human Development Index, a measurement that considers health, education and income.16 Despite economic growth in recent years, 60% of the population still lives below the international poverty line of US $1.25 per day.15 The majority of the population (67%) lives in rural areas.15 Less than one-half of the population (47%) have access to an improved water source, and only 19% have access to an improved sanitation facility.15 Access to healthcare is limited by a lack of qualified health workers, with only 1268 physicians in the National Health System of Mozambique in 2011.17 Including both physicians and nurses, there were 64.5 healthcare workers per 100 000 population in 2011, far below the minimum acceptable health worker density threshold of 230/100 000.17 Chókwè district is a predominantly rural, agricultural area. The city of Chókwè, which is the administrative capital of Chókwè District, is located 90 km west of the Gaza Province capital city of Xai-Xai and 230 km northwest of Maputo, Mozambique's capital. HRC serves a catchment area of approximately 200 000 people, of whom approximately 53 000 live in the city of Chókwè. The hospital is divided into four wards: medicine (26 beds); paediatrics (26 beds); maternity (38 beds); and surgery (28 beds). HRC also provides services in emergency care, radiology, physical therapy, dentistry, ophthalmology, orthopaedics and psychiatry. Resources include a laboratory, X-ray machine and pharmacy. Patients requiring a higher level of care are transferred to tertiary hospitals in the provincial capital of Xai-Xai or in the country capital of Maputo. HRC employs two non-physician surgeons, ‘técnicos de cirurgia’ (technicians of surgery), who are the only clinicians providing surgery at HRC. Técnicos de cirurgia are mid-level providers who have completed 3 additional years of surgical training and serve as the primary surgical workforce in rural Mozambique.18 Data were collected from all inpatients at HRC during the 6-week period between 20 June and 3 August 2012. Data included date of admission and discharge, age, sex, city of residence, hospital ward (medicine, paediatrics, maternity or surgery) and diagnosis. Patients who were admitted to the maternity ward but underwent surgery (Caesarean section, hysterectomy, etc.) were included as surgical patients. Global positioning system coordinates of cities of residence were found to calculate the Euclidean distance from each patient's city or village to HRC. The Euclidean distance is measured according to the straight line between two points. This was used to maintain consistency since road maps were not always accurate and patients may take paths off marked roads. Using population data from the August 2007 Mozambique census (the most recent population data available), the proportion of patients from each city was calculated to estimate the percent of the population that was admitted to the hospital. These proportions were compared between wards. Six patients came from cities in which the population was not known; these patients were grouped with nearby cities and included in the analysis. Age, sex, distance travelled and length of stay (LOS) by ward, and between surgical versus non-surgical patients, were compared. Proportions were compared using χ2 tests while continuous variables were compared using t tests. A p-value of <0.05 was defined as statistically significant. Data were analysed using ArcGIS 10 (Esri, Redlands, CA, USA) and STATA 64-bit Special Edition v.11.2 (StataCorp LP, College Station, TX, USA). Institutional Review Boards at University of California, San Diego and the National Bioethics Committee of Mozambique approved this project.
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