Healthcare access is vitally important to improving health, preventing disease and death, and improving the quality of life of the population. Access to healthcare has been commonly described and understood by geographic, economic, or cultural terms or determinants by public health practitioners and researchers. Geographic healthcare access refers to the supply (adequate number of), diversity (difference in type, service, education, and skills), and distribution (more or less in numbers by region) of healthcare providers and services. For a country like Bangladesh, physical or geographic accessibility is a major issue as many parts of the country are not yet well-connected with the rest of the country. Healthcare access research has previously focused more on non-geographical issues, e.g., cost, culture, awareness, education, income, and supply and skills of healthcare professionals, and research on geographic access to healthcare is nearly absent in Bangladesh.
Geographical accessibility issues affect certain population groups more than others and these population groups are more likely to suffer additional health problems. Many reports have highlighted that remote and rural populations in Bangladesh cannot access timely and adequate healthcare. For example, people in certain upazilas of the hilly districts may take half a day to a full day of travel to come to the nearest tertiary care hospital like Chattagram Medical College hospital which compromises their recovery from medical conditions where urgent care receiving is critical. Numerous newspaper stories have reported that children with severe burn injuries could not make it to a burn center. In the long rainy seasons, a large portion of low-lying Bangladesh goes under water making travel even slower and more difficult.
Geographic Information System (GIS) has been a growing tool for public health practitioners and researchers since the 1990s and is now a well-accepted public health analytical technique. One of its most powerful features is its ability to geocode or georeference statistics or demographic data onto a map for an easy-to-understand, aesthetically pleasing visual display of health access information. The use of spatial statistical methods can create smoothed maps depicting the cluster or density of target populations to the health care provider location such as a cardiologist's practice chamber or a burn center. GIS has allowed researchers studying health to combine information on spatial accessibility to available healthcare resources. It has provided a method for mathematically and statistically calculating accessibility scores between healthcare facilities and healthcare consumers.
GIS has allowed researchers in health fields to develop models of analysis in order to investigate questions about spatial accessibility as well as the equitability of health access. Guagliardo (Spatial accessibility of primary care: concepts, methods, and challenges; International Journal of Health Geographics, 2004) described four main categories of measures for evaluating geographic accessibility to health care: provider-to-population ratio, distance to the nearest provider, the average distance to a set of providers, and gravitational models of provider influence. Provider-to-population ratios can be computed for bounded areas, such as districts, upazilas, metropolitan areas, or unions. These are the geographic units of analysis where the numerator can be the number of physicians, and clinics and the denominator is the population of that area. Travel to the nearest provider is measured from a patient's place of residence. Travel cost is often measured in travel distance or travel time via the existing transportation network. Average travel to the provider is measured from any patient or population point of interest and from that point the travel distance to all providers is summed and averaged. It is a combined indicator of accessibility and availability. Gravity models were initially developed for land use planning, these models can provide the most valid measures of spatial accessibility.
Spatial aspects of health and illness are useful in many ways. For example-- 1) Where are diseases found? In Bangladesh, certain diseases like leprosy and malaria are known to have clustered in certain regions; 2) How are diseases related to the environment? In Bangladesh, asthma and other respiratory problems are highly prevalent in more air-polluted areas, with river pollution so high in the vicinity of Dhaka, there will be distinct disease patterns among people living nearby these rivers; 3) Where do people go to seek health care? Tertiary care hospitals are located mostly in Dhaka and only in certain large district towns in Bangladesh; it helps to know how long a patient has to travel in terms of distance and time to seek care.
In a GIS, the data usually include descriptive information. For example, a data set of hospitals in Bangladesh can be mapped. The descriptive data allows to search and display of associated attributes (e.g., number of ophthalmologists, hospital beds, types of specialized services offered, etc). GIS cannot completely provide solutions to understanding the distribution of health needs as there are many non-spatial factors, such as social class, income, age, and sex, which contribute to understanding spatial accessibility, but it is a powerful tool in epidemiological studies, given that maps are prepared and evaluated with accuracy. It is an increasingly accepted method of technology with the capability to evaluate the accessibility of health services for the population. Research in assessing spatial accessibility needs to expand in Bangladesh to accurately identify gaps in health access between healthcare providers and target populations.
Dr. Hasnat M Alamgir is a Professor and Chair of Public Health at IUBAT- International University of Business Agriculture and Technology, Dhaka.
