Geographical accessibility of emergency neonatal care services in Ethiopia: analysis using the 2016 Ethiopian Emergency Obstetric and Neonatal Care Survey

BMJ Open, Volume 12, No. 6, Year 2022

Interpretation

Introduction Access to emergency neonatal health services has not been explored widely in the Ethiopian context. Accessibility to health services is a function of the distribution and location of services, including distance, travel time, cost and convenience. Measuring the physical accessibility of health services contributes to understanding the performance of health systems, thereby enabling evidence-based health planning and policies. The physical accessibility of Ethiopian health services, particularly emergency neonatal care (EmNeC) services, is unknown. Objective To analyse the physical accessibility of EmNeC services at the national and subnational levels in Ethiopia. Methods We analysed the physical accessibility of EmNeC services within 30, 60 and 120 min of travel time in Ethiopia at a national and subnational level. We used the 2016 Ethiopian Emergency Obstetric and Neonatal Care survey in addition to several geospatial data sources. Results We estimated that 21.4%, 35.9% and 46.4% of live births in 2016 were within 30, 60 and 120 min of travel time of fully EmNeC services, but there was considerable variation across regions. Addis Ababa and the Hareri regional state had full access (100% coverage) to EmNeC services within 2 hours travel time, while the Afar (15.3%) and Somali (16.3%) regional states had the lowest access. Conclusions The physical access to EmNeC services in Ethiopia is well below the universal health coverage expectations stated by the United Nations. Increasing the availability of EmNeC to health facilities where routine delivery services currently are taking place would significantly increase physical access. Our results reinforce the need to revise service allocations across administrative regions and consider improving disadvantaged areas in future health service planning. The Ethiopian health system is based on the primary healthcare approach with three levels of care. The primary level includes primary hospitals, health centres and health posts (the lowest-level facility at a village level). The secondary level includes specialty centres (eg, maternal and child health (MCH) specialty centres), specialty clinics and general hospitals that serve as referral centres for primary hospitals, and the tertiary level includes specialised referral hospitals.26 Most of the EmNeC signal functions are performed in hospitals and MCH specialty centres.18 A specialty centre differs from a specialty clinic as specialty centres have inpatient admissions and offer 24 hours emergency services. A specialty centre differs from a hospital in that they do not offer the full spectrum of specialties required for a general hospital.27 The target population for this analysis were all live births in Ethiopia taken from the 2016 UN estimates of numbers of live births per 1 km grid square.28 The primary outcome variable in this study was accessibility to fully functioning EmNeC within 30 min, 1 hour and 2 hours travel time at a national and regional level. Secondary outcomes include accessibility of fully functioning health services through walking travel and access to health facilities with partial EmNeC signal functions. Accessibility was defined as the access from a residence to a health facility within 2 hours of travel time based on the WHO optimal access definition.29 The facilities were considered to be fully functioning if all the seven signal functions for EmNeC were available in the past 3 months before the survey. No patient involved. We used three data groups for this analysis: statistical, geospatial and national norms data. The statistical data included national and regional population sizes and the number of functional EmNeC health facilities. The geospatial data were regional administrative boundary data, geographical location of all health facilities providing delivery services, road network, hydrographical network, land cover, digital elevation model (DEM) data and spatial distribution of live births in Ethiopia in 2015. The national norms data include the maximum travel speed expected for a motor vehicle on the different road types and the average capacity of health facilities that they could serve. We used the Ethiopian 2016 EmONC survey, which is a national census of health facilities providing maternal and neonatal services.18 A total of 3804 health facilities providing delivery services were included in the EmONC survey. Ethiopia’s 2016 produced boundary shapefile, a geospatial vector data format matching the level of disaggregation of the subnational statistical data, was accessed through OpenAFRICA30; land cover and DEM data of 2015, a representation of the bare ground topographical surface of the Earth were accessed from the DIVA-GIS webpage.31 The 2015 raster data for live births per 1 km grid square was accessed via the WorldPop webpage.28 We used OpenStreetMaps via the World Food Programme data repository of 201732 to estimate travel speeds for motorised vehicles based on the primary, secondary, and tertiary and unclassified road surfaces. We used DEM data to estimate the effects of slopes on travel time.33 The barrier to travel (hydrographical data) was obtained from RCMRD GeoPortal34 and DIVA-GIS31 web pages produced in 2015. We created a travel scenario for walking and motorised transportation based on the land cover structure and road types. We assumed that walking speed ranged from zero km/hour for water bodies to 2.5 km/hour for established residential areas, assuming a pregnant woman in her last month of pregnancy would be able to walk at half the average walking speed as used elsewhere.35 We assumed driving speeds of 100, 70, 50 and 30 km per hour for primary, secondary, tertiary and unclassified road types based on the country’s speed limit.36 We used these speeds as ambulances would be able to travel at the maximum speed in emergency situations. We also conducted a sensitivity analysis for fully EmNeC services coverage, lowering the maximum vehicle speed by 25%. The road network data were classified based on Ethiopian speed limit norms. The main road classifications in Ethiopia are primary, secondary, tertiary and unclassified.32 However, the road network data available online includes several classifications, including the linking roads between primary roads-so we need to reclassify into the above four main classifications. Primary, primary link, motorway and trunk roads were classified as primary, secondary and secondary links as secondary, tertiary and tertiary links as tertiary and track and unclassified were merged as unclassified road classes. We assigned the maximum capacity for each health facility category based on the standard WHO assumption of births per skilled birth attendant per year.37 We assigned 175, 100, 75 and 50 births per skilled birth attendant per year for hospitals, MCH specialty centres, health centres and clinics. We then multiplied the number of births per year by the number of skilled birth attendants at each facility to estimate the total number of possible births per year at each health facility. We integrated multiple geospatial datasets in AccessMod, which is a free, open-source software package developed by the WHO. AccessMod uses geographical information systems (GIS),38 which are computer-based systems to gather, store, retrieve, analyse and display spatial data, to assess health facilities physical accessibility and geographical coverage.39 AccessMod models the coverage of catchment areas linked to an existing health facility network integrating population distribution, travel time and the population coverage capacity specific to each health facility in the network.40 AccessMod computes catchment areas using the least-cost path algorithm.41 The least-cost path approach calculates the distance between a focal location and all cells in the surroundings, dividing surface areas into grid cells. It identifies the best path from one point to another over a cost surface, identifying the cost of travelling through each grid cell, which has been given to cost how expensive, it is to pass through that cell.42 The cost given to each cell is the travelling time to cross the grid cell, which is determined through the travelling speed attributed to the elevation and land cover of the cell. Finally, it produces a point estimate of cumulative access coverage of health services to catchment areas population. The vector and raster geospatial data files were projected based on Ethiopia’s geographical coordinate system at Adindan UTM zone 37N43 to make it suitable for analysis. A projection is the means by which we display the coordinate system and data on a flat surface, such as a piece of paper or a digital screen. A projected coordinate system is a two-dimensional flat surface, and locations, in this case, are identified by x, y coordinates.44

AI Digest

Study Justification:

– The study aims to explore the geographical accessibility of emergency neonatal care (EmNeC) services in Ethiopia, which has not been widely explored before.
– Access to health services, including distance, travel time, cost, and convenience, is crucial for effective healthcare delivery.
– Understanding the physical accessibility of EmNeC services can contribute to evidence-based health planning and policies, ultimately improving the performance of the health system.

Study Highlights:

– The study analyzed the physical accessibility of EmNeC services within 30, 60, and 120 minutes of travel time at the national and subnational levels in Ethiopia.
– Results showed that a significant proportion of live births in 2016 (21.4%, 35.9%, and 46.4%) were within the specified travel time of fully functioning EmNeC services.
– However, there was considerable variation across regions, with some regions having full access (100% coverage) within 2 hours, while others had much lower access (e.g., Afar and Somali regions).
– The study highlights the need to revise service allocations across administrative regions and improve disadvantaged areas in future health service planning to increase physical access to EmNeC services.

Recommendations for Lay Reader and Policy Maker:

– Increase the availability of EmNeC services in health facilities where routine delivery services currently take place to improve physical access.
– Revise service allocations across administrative regions to ensure equitable access to EmNeC services.
– Consider improving disadvantaged areas in future health service planning to address the disparities in access.
– Aim for universal health coverage expectations stated by the United Nations in terms of physical access to EmNeC services.

Key Role Players:

– Ministry of Health: Responsible for policy development, resource allocation, and implementation of recommendations.
– Regional Health Bureaus: Responsible for implementing recommendations at the regional level and coordinating with health facilities.
– Health Facility Managers: Responsible for ensuring the availability and accessibility of EmNeC services in their respective facilities.
– Community Health Workers: Involved in community outreach and education to improve awareness and utilization of EmNeC services.

Cost Items for Planning Recommendations:

– Infrastructure Development: Construction or renovation of health facilities to accommodate EmNeC services.
– Equipment and Supplies: Procurement of medical equipment and supplies required for EmNeC services.
– Human Resources: Recruitment, training, and retention of skilled healthcare professionals for EmNeC services.
– Transportation: Provision of ambulances or other means of transportation for emergency transfers.
– Monitoring and Evaluation: Establishing systems to monitor the implementation and impact of the recommendations.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are areas for improvement. The study used a nationally representative survey and multiple geospatial data sources to analyze the physical accessibility of emergency neonatal care services in Ethiopia. The results show that the physical access to these services is below the universal health coverage expectations set by the United Nations. The study provides specific percentages of live births within different travel times of fully functioning EmNeC services, as well as regional variations in access. The study also suggests actionable steps to improve access, such as increasing the availability of EmNeC services in health facilities where routine delivery services are already provided. However, the abstract does not provide information on the sample size or methodology used in the survey, which could affect the generalizability of the findings. Additionally, the abstract does not mention any limitations or potential biases in the study. To improve the strength of the evidence, future research could include a larger sample size and provide more details on the survey methodology and potential limitations.

Abstract

The Ethiopian health system is based on the primary healthcare approach with three levels of care. The primary level includes primary hospitals, health centres and health posts (the lowest-level facility at a village level). The secondary level includes specialty centres (eg, maternal and child health (MCH) specialty centres), specialty clinics and general hospitals that serve as referral centres for primary hospitals, and the tertiary level includes specialised referral hospitals.26 Most of the EmNeC signal functions are performed in hospitals and MCH specialty centres.18 A specialty centre differs from a specialty clinic as specialty centres have inpatient admissions and offer 24 hours emergency services. A specialty centre differs from a hospital in that they do not offer the full spectrum of specialties required for a general hospital.27 The target population for this analysis were all live births in Ethiopia taken from the 2016 UN estimates of numbers of live births per 1 km grid square.28 The primary outcome variable in this study was accessibility to fully functioning EmNeC within 30 min, 1 hour and 2 hours travel time at a national and regional level. Secondary outcomes include accessibility of fully functioning health services through walking travel and access to health facilities with partial EmNeC signal functions. Accessibility was defined as the access from a residence to a health facility within 2 hours of travel time based on the WHO optimal access definition.29 The facilities were considered to be fully functioning if all the seven signal functions for EmNeC were available in the past 3 months before the survey. No patient involved. We used three data groups for this analysis: statistical, geospatial and national norms data. The statistical data included national and regional population sizes and the number of functional EmNeC health facilities. The geospatial data were regional administrative boundary data, geographical location of all health facilities providing delivery services, road network, hydrographical network, land cover, digital elevation model (DEM) data and spatial distribution of live births in Ethiopia in 2015. The national norms data include the maximum travel speed expected for a motor vehicle on the different road types and the average capacity of health facilities that they could serve. We used the Ethiopian 2016 EmONC survey, which is a national census of health facilities providing maternal and neonatal services.18 A total of 3804 health facilities providing delivery services were included in the EmONC survey. Ethiopia’s 2016 produced boundary shapefile, a geospatial vector data format matching the level of disaggregation of the subnational statistical data, was accessed through OpenAFRICA30; land cover and DEM data of 2015, a representation of the bare ground topographical surface of the Earth were accessed from the DIVA-GIS webpage.31 The 2015 raster data for live births per 1 km grid square was accessed via the WorldPop webpage.28 We used OpenStreetMaps via the World Food Programme data repository of 201732 to estimate travel speeds for motorised vehicles based on the primary, secondary, and tertiary and unclassified road surfaces. We used DEM data to estimate the effects of slopes on travel time.33 The barrier to travel (hydrographical data) was obtained from RCMRD GeoPortal34 and DIVA-GIS31 web pages produced in 2015. We created a travel scenario for walking and motorised transportation based on the land cover structure and road types. We assumed that walking speed ranged from zero km/hour for water bodies to 2.5 km/hour for established residential areas, assuming a pregnant woman in her last month of pregnancy would be able to walk at half the average walking speed as used elsewhere.35 We assumed driving speeds of 100, 70, 50 and 30 km per hour for primary, secondary, tertiary and unclassified road types based on the country’s speed limit.36 We used these speeds as ambulances would be able to travel at the maximum speed in emergency situations. We also conducted a sensitivity analysis for fully EmNeC services coverage, lowering the maximum vehicle speed by 25%. The road network data were classified based on Ethiopian speed limit norms. The main road classifications in Ethiopia are primary, secondary, tertiary and unclassified.32 However, the road network data available online includes several classifications, including the linking roads between primary roads-so we need to reclassify into the above four main classifications. Primary, primary link, motorway and trunk roads were classified as primary, secondary and secondary links as secondary, tertiary and tertiary links as tertiary and track and unclassified were merged as unclassified road classes. We assigned the maximum capacity for each health facility category based on the standard WHO assumption of births per skilled birth attendant per year.37 We assigned 175, 100, 75 and 50 births per skilled birth attendant per year for hospitals, MCH specialty centres, health centres and clinics. We then multiplied the number of births per year by the number of skilled birth attendants at each facility to estimate the total number of possible births per year at each health facility. We integrated multiple geospatial datasets in AccessMod, which is a free, open-source software package developed by the WHO. AccessMod uses geographical information systems (GIS),38 which are computer-based systems to gather, store, retrieve, analyse and display spatial data, to assess health facilities physical accessibility and geographical coverage.39 AccessMod models the coverage of catchment areas linked to an existing health facility network integrating population distribution, travel time and the population coverage capacity specific to each health facility in the network.40 AccessMod computes catchment areas using the least-cost path algorithm.41 The least-cost path approach calculates the distance between a focal location and all cells in the surroundings, dividing surface areas into grid cells. It identifies the best path from one point to another over a cost surface, identifying the cost of travelling through each grid cell, which has been given to cost how expensive, it is to pass through that cell.42 The cost given to each cell is the travelling time to cross the grid cell, which is determined through the travelling speed attributed to the elevation and land cover of the cell. Finally, it produces a point estimate of cumulative access coverage of health services to catchment areas population. The vector and raster geospatial data files were projected based on Ethiopia’s geographical coordinate system at Adindan UTM zone 37N43 to make it suitable for analysis. A projection is the means by which we display the coordinate system and data on a flat surface, such as a piece of paper or a digital screen. A projected coordinate system is a two-dimensional flat surface, and locations, in this case, are identified by x, y coordinates.44

Materials

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health in Ethiopia:

1. Telemedicine: Implementing telemedicine services can provide remote access to healthcare professionals for pregnant women in rural areas. This would allow them to receive medical advice, consultations, and monitoring without the need for long-distance travel.

2. Mobile clinics: Utilizing mobile clinics equipped with necessary medical equipment and staff can bring maternal health services closer to remote communities. These clinics can travel to different locations, providing prenatal care, check-ups, and emergency services.

3. Community health workers: Training and deploying community health workers can help bridge the gap between healthcare facilities and remote communities. These workers can provide basic maternal health services, education, and referrals, ensuring that pregnant women receive the care they need.

4. Improving transportation infrastructure: Investing in road infrastructure and transportation systems can reduce travel time and improve access to healthcare facilities. This could involve building new roads, improving existing ones, and implementing transportation services specifically for pregnant women.

5. Mobile applications: Developing mobile applications that provide information on prenatal care, nutrition, and emergency services can empower pregnant women to take control of their health. These apps can also provide reminders for appointments and medication, ensuring that women receive timely care.

6. Public-private partnerships: Collaborating with private healthcare providers can help expand access to maternal health services. This could involve partnering with private clinics and hospitals to provide subsidized or free services to underserved communities.

7. Health education campaigns: Conducting targeted health education campaigns can raise awareness about the importance of prenatal care and maternal health. These campaigns can provide information on available services, encourage early prenatal visits, and promote healthy practices during pregnancy.

It’s important to note that the specific implementation of these innovations would require further research, planning, and collaboration with relevant stakeholders.

AI Innovations Description

The recommendation to improve access to maternal health based on the provided information is to increase the availability of emergency neonatal care (EmNeC) services in health facilities where routine delivery services are currently taking place. This can significantly improve physical access to maternal health services in Ethiopia.

The analysis conducted in the study revealed that the physical access to EmNeC services in Ethiopia is below the universal health coverage expectations set by the United Nations. By increasing the availability of EmNeC services in health facilities, more women will have access to emergency care during childbirth, reducing the risk of maternal and neonatal mortality.

To implement this recommendation, health service planning should consider revising service allocations across administrative regions and prioritizing the improvement of disadvantaged areas. This will help ensure that EmNeC services are distributed more evenly across the country, addressing the regional disparities in access.

Additionally, efforts should be made to strengthen the capacity of health facilities to provide EmNeC services. This may involve training healthcare providers, equipping facilities with necessary medical supplies and equipment, and ensuring the availability of skilled birth attendants.

Overall, improving access to maternal health in Ethiopia requires a comprehensive approach that focuses on increasing the availability of EmNeC services and addressing regional disparities in access. By implementing these recommendations, the Ethiopian health system can make significant strides towards improving maternal and neonatal health outcomes.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health in Ethiopia:

1. Increase the availability of emergency neonatal care (EmNeC) services: This can be achieved by ensuring that all health facilities providing routine delivery services also have the necessary equipment and trained staff to provide EmNeC services. This would help to increase the physical access to EmNeC services, especially in disadvantaged areas.

2. Improve service allocations across administrative regions: The study highlights the considerable variation in access to EmNeC services across different regions in Ethiopia. Revising service allocations and redistributing resources to areas with lower access can help to improve overall access to maternal health services.

3. Enhance transportation infrastructure: Improving road networks and transportation facilities can significantly reduce travel time and increase access to maternal health services. This could involve building new roads, improving existing ones, and ensuring that ambulances and other transportation options are readily available in remote areas.

4. Strengthen referral systems: Establishing effective referral systems between primary healthcare facilities and specialty centers can ensure that pregnant women with complications receive timely and appropriate care. This would involve training healthcare providers at primary facilities to identify high-risk cases and refer them to higher-level facilities when necessary.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed using the following steps:

1. Define the indicators: Identify specific indicators that measure access to maternal health, such as the percentage of live births within a certain travel time of fully functioning EmNeC services.

2. Collect data: Gather relevant data on the current distribution of health facilities, transportation infrastructure, population distribution, and other factors that affect access to maternal health services.

3. Develop a simulation model: Use a geographic information system (GIS) software, such as AccessMod, to model the coverage of catchment areas linked to the existing health facility network. This model should integrate population distribution, travel time, and the capacity of each health facility to estimate the physical accessibility and geographical coverage of maternal health services.

4. Apply the recommendations: Modify the simulation model to incorporate the proposed recommendations, such as increasing the availability of EmNeC services, improving service allocations, and enhancing transportation infrastructure. Adjust the relevant parameters in the model to reflect the expected changes resulting from these recommendations.

5. Analyze the results: Compare the simulation results before and after implementing the recommendations to assess the impact on access to maternal health services. Evaluate the changes in indicators such as the percentage of live births within a certain travel time of fully functioning EmNeC services.

6. Refine and iterate: Based on the analysis, refine the recommendations and simulation model as needed. Repeat the simulation process to further optimize the strategies for improving access to maternal health.

By following this methodology, policymakers and healthcare planners can gain insights into the potential impact of different recommendations on improving access to maternal health services in Ethiopia.

Author

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1136/bmjopen-2021-058648

Research Areas:

Environmental, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Quantitative