Clinical, logistic, and geographic factors in ensuring adequate access to implant removals: A cross-sectional survey of public facilities and GIS modeling of geographic access in two districts of Senegal.

Introduction: Ensuring adequate access to contraceptive implant removal services requires an understanding of potential clinical, logistical, and geographic challenges. Methods: We conducted a cross-sectional survey of 39 public health facilities in two districts of Senegal. To assess facility readiness, we reported the proportion of facilities meeting all minimum conditions for regular and difficult implant removals. We then describe characteristics of referral networks. Geographic access modeling was conducted in a geographic information system to estimate the proportion of women of reproductive age living within specific travel times of facilities ready for regular and difficult removals. Results: 72% of facilities met all conditions for regular removals, and 8% for difficult removals. In both cases, the main gaps related to equipment availability (79% of facilities had the minimum equipment for regular removals and 8% for difficult removals). 72% of facilities organized in three referral networks sent clients to other facilities for cases they could not manage. Of 11 receiving or single-network facilities, seven were ready for regular removals and one for difficult removals. Altogether, 36% of women in Dakar Centre and 99% of women in Kolda lived within two hours of a facility that was equipped to handle regular removals, compared to 15% and 69%, respectively, for difficult removals. Conclusion: Data such as those provided in this assessment are important to provide a realistic picture of the state of readiness of the health system and its ability to meet the inevitable demand for implant removals. Referral networks should be considered as an emerging strategy to avail sufficient capacity at the systems level, including for managing difficult removals. However, careful thought should be given to the location of facilities that are ready to receive cases in order to target upgrades.

Geographic access to emergency obstetric services: a model incorporating patient bypassing using data from Mozambique.

INTRODUCTION: Targeted approaches to further reduce maternal mortality require thorough understanding of the geographic barriers that women face when seeking care. Common measures of geographic access do not account for the time needed to reach services, despite substantial evidence that links proximity with greater use of facility services. Further, methods for measuring access often ignore the evidence that women frequently bypass close facilities based on perceptions of service quality. This paper aims to adapt existing approaches for measuring geographic access to better reflect women's bypassing behaviour, using data from Mozambique. METHODS: Using multiple data sources and modelling within a geographic information system, we calculated two segments of a patient's time to care: (1) home to the first preferred facility, assuming a woman might travel longer to reach a facility she perceived to be of higher quality; and (2) referral between the first preferred facility and facilities providing the highest level of care (eg, surgery). Combined, these two segments are total travel time to highest care. We then modelled the impact of expanding services and emergency referral infrastructure. RESULTS: The combination of upgrading geographically strategic facilities to provide the highest level of care and providing transportation to midlevel facilities modestly increased the percentage of the population with 2-hour access to the highest level of care (from 41% to 45%). The mean transfer time between facilities would be reduced by 39% (from 2.9 to 1.8 hours), and the mean total journey time by 18% (from 2.5 to 2.0 hours). CONCLUSION: This adapted methodology is an effective tool for health planners at all levels of the health system, particularly to identify areas of very poor access. The modelled changes indicate substantial improvements in access and identify populations outside timely access for whom more innovative interventions are needed.

Geographic access to emergency obstetric services: a model incorporating patient bypassing using data from Mozambique / Geographic access to emergency obstetric services: a model incorporating patient bypassing using data from Mozambique

Targeted approaches to further reduce maternal mortality require thorough understanding of the geographic barriers that women face when seeking care. Common measures of geographic access do not account for the time needed to reach services, despite substantial evidence that links proximity with greater use of facility services. Further, methods for measuring access often ignore the evidence that women frequently bypass close facilities based on perceptions of service quality. This paper aims to adapt existing approaches for measuring geographic access to better reflect women's bypassing behaviour, using data from Mozambique. Using multiple data sources and modelling within a geographic information system, we calculated two segments of a patient's time to care: (1) home to the first preferred facility, assuming a woman might travel longer to reach a facility she perceived to be of higher quality; and (2) referral between the first preferred facility and facilities providing the highest level of care (eg, surgery). Combined, these two segments are total travel time to highest care. We then modelled the impact of expanding services and emergency referral infrastructure. The combination of upgrading geographically strategic facilities to provide the highest level of care and providing transportation to midlevel facilities modestly increased the percentage of the population with 2-hour access to the highest level of care (from 41% to 45%). The mean transfer time between facilities would be reduced by 39% (from 2.9 to 1.8 hours), and the mean total journey time by 18% (from 2.5 to 2.0 hours). This adapted methodology is an effective tool for health planners at all levels of the health system, particularly to identify areas of very poor access. The modelled changes indicate substantial improvements in access and identify populations outside timely access for whom more innovative interventions are needed.

User fees and maternity services in Ethiopia.

OBJECTIVES: To examine user fees for maternity services and how they relate to provision, quality, and use of maternity services in Ethiopia. METHODS: The national assessment of emergency obstetric and newborn care (EmONC) examined user fees for maternity services in 751 health facilities that provided childbirth services in 2008. RESULTS: Overall, only about 6.6% of women gave birth in health facilities. Among facilities that provided delivery care, 68% charged a fee in cash or kind for normal delivery. Health centers should be providing maternity services free of charge (the healthcare financing proclamation), yet 65% still charge for some aspect of care, including drugs and supplies. The average cost for normal and cesarean delivery was US $7.70 and US $51.80, respectively. Nineteen percent of these facilities required payment in advance for treatment of an obstetric emergency. The health facilities that charged user fees had, on average, more delivery beds, deliveries (normal and cesarean), direct obstetric complications treated, and a higher ratio of skilled birth attendants per 1000 deliveries than those that did not charge. The case fatality rate was 3.8% and 7.1% in hospitals that did and did not charge user fees, respectively. CONCLUSION: Utilization of maternal health services is extremely low in Ethiopia and, although there is a government decree against charging for maternity service, 65% of health centers do charge for some aspects of maternal care. As health facilities are not reimbursed by the government for the costs of maternity services, this loss of revenue may account for the more and better services offered in facilities that continue to charge user fees. User fees are not the only factor that determines utilization in settings where the coverage of maternity services is extremely low. Additional factors include other out-of-pocket payments such as cost of transport and food and lodging for accompanying relatives. It is important to keep quality of care in mind when user fees are under discussion.

Ethiopia's assessment of emergency obstetric and newborn care: setting the gold standard for national facility-based assessments.

OBJECTIVE: To describe the methods used to implement Ethiopia's 2008 emergency obstetric and newborn care services (EmONC) assessment; highlight how the collaborative process contributed to immediate integration of results into national and subnational planning; and explain how the experience informed the development of a set of tools providing best practices and guidelines for other countries conducting similar assessments. METHODS: A team of maternal and newborn health experts from the Federal Ministry of Health (FMOH), the United Nations Children's Fund (UNICEF), the World Health Organization (WHO), and the United Nations Population Fund (UNFPA), together with representatives from the Ethiopian Society of Obstetricians and Gynecologists, provided technical guidance for the 18-month process and facilitated demand for and use of the assessment results. Eighty-four trained data collectors administered 9 data collection modules in 806 public and private facilities. Field work and data were managed by a private firm who, together with the core team, implemented a multi-layered plan for data quality. Columbia University's Averting Maternal Death and Disability Program provided technical assistance. RESULTS: Results were published in national and regional reports and in 1-page facility factsheets informing subnational planning activities. Assessment results-which have been published in journal articles-informed water infrastructure improvements, efforts to expand access to magnesium sulfate, and FMOH and UN planning documents. The assessment also established a permanent database for future monitoring of the health system, including geographic locations of surveyed facilities. CONCLUSION: Ethiopia's assessment was successful largely because of active local leadership, a collaborative process, ample financial and technical support, and rapid integration of results into health system planning.

Using a GIS to model interventions to strengthen the emergency referral system for maternal and newborn health in Ethiopia.

OBJECTIVES: To show how GIS can be used by health planners to make informed decisions about interventions to increase access to emergency services. METHODS: A combination of data sources, including the 2008 national Ethiopian baseline assessment for emergency obstetric and newborn care that covered 797 geo-coded health facilities, LandScan population data, and road network data, were used to model referral networks and catchment areas across 2 regions of Ethiopia. STATA and ArcGIS software extensions were used to model different scenarios for strengthening the referral system, defined by the structural inputs of transportation and communication, and upgrading facilities, to compare the increase in access to referral facilities. RESULTS: Approximately 70% of the population of Tigray and Amhara regions is served by facilities that are within a 2-hour transfer time to a hospital with obstetric surgery. By adding vehicles and communication capability, this percentage increased to 83%. In a second scenario, upgrading 7 strategically located facilities changed the configuration of the referral networks, and the percentage increased to 80%. By combining the 2 strategies, 90% of the population would be served by midlevel facilities within 2 hours of obstetric surgery. The mean travel time from midlevel facilities to surgical facilities would be reduced from 121 to 64 minutes in the scenario combining the 2 interventions. CONCLUSIONS: GIS mapping and modeling enable spatial and temporal analyses critical to understanding the population's access to health services and the emergency referral system. The provision of vehicles and communication and the upgrading of health centers to first level referral hospitals are short- and medium-term strategies that can rapidly increase access to lifesaving services.