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Cao WR, Shakya P, Karmacharya B, Xu DR, Hao YT, Lai YS. Equity of geographical access to public health facilities in Nepal. BMJ Glob Health 2021; 6:bmjgh-2021-006786. [PMID: 34706879 PMCID: PMC8552161 DOI: 10.1136/bmjgh-2021-006786] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/03/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction Geographical accessibility is important against health equity, particularly for less developed countries as Nepal. It is important to identify the disparities in geographical accessibility to the three levels of public health facilities across Nepal, which has not been available. Methods Based on the up-to-date dataset of Nepal formal public health facilities in 2021, we measured the geographical accessibility by calculating the travel time to the nearest public health facility of three levels (ie, primary, secondary and tertiary) across Nepal at 1×1 km2 resolution under two travel modes: walking and motorised. Gini and Theil L index were used to assess the inequality. Potential locations of new facilities were identified for best improvement of geographical efficiency or equality. Results Both geographical accessibility and its equality were better under the motorised mode compared with the walking mode. If motorised transportation is available to everyone, the population coverage within 5 min to any public health facilities would be improved by 62.13%. The population-weighted average travel time was 17.91 min, 39.88 min and 69.23 min and the Gini coefficients 0.03, 0.18 and 0.42 to the nearest primary, secondary and tertiary facilities, respectively, under motorised mode. For primary facilities, low accessibility was found in the northern mountain belt; for secondary facilities, the accessibility decreased with increased distance from the district centres; and for tertiary facilities, low accessibility was found in most areas except the developed areas like zonal centres. The potential locations of new facilities differed for the three levels of facilities. Besides, the majority of inequalities of geographical accessibility were from within-province. Conclusion The high-resolution geographical accessibility maps and the assessment of inequality provide valuable information for health resource allocation and health-related planning in Nepal.
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Affiliation(s)
- Wen-Rui Cao
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Prabin Shakya
- Departments of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Biraj Karmacharya
- Departments of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Dong Roman Xu
- ACACIA Labs, SMU Institute for Global Health (SIGHT) and Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Center for WHO Studies and Department of Health Management, School of Health Management of Southern Medical University, Guangzhou, Guangdong, China
| | - Yuan-Tao Hao
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Ying-Si Lai
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China .,Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, Guangdong, China
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Chirambo GB, Thompson M, Hardy V, Ide N, Hwang PH, Dharmayat K, Mastellos N, Heavin C, O'Connor Y, Muula AS, Andersson B, Carlsson S, Tran T, Hsieh JCL, Lee HY, Fitzpatrick A, Joseph Wu TS, O'Donoghue J. Effectiveness of Smartphone-Based Community Case Management on the Urgent Referral, Reconsultation, and Hospitalization of Children Aged Under 5 Years in Malawi: Cluster-Randomized, Stepped-Wedge Trial. J Med Internet Res 2021; 23:e25777. [PMID: 34668872 PMCID: PMC8567152 DOI: 10.2196/25777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 02/11/2021] [Accepted: 08/10/2021] [Indexed: 11/18/2022] Open
Abstract
Background Integrated community case management (CCM) has led to reductions in child mortality in Malawi resulting from illnesses such as malaria, pneumonia, and diarrhea. However, adherence to CCM guidelines is often poor, potentially leading to inappropriate clinical decisions and poor outcomes. We determined the impact of an e-CCM app on the referral, reconsultation, and hospitalization rates of children presenting to village clinics in Malawi. Objective We determined the impact of an electronic version of a smartphone-based CCM (e-CCM) app on the referral, reconsultation, and hospitalization rates of children presenting to village clinics in Malawi. Methods We used a stepped-wedge, cluster-randomized trial to compare paper-based CCM (control) with and without the use of an e-CCM app on smartphones from November 2016 to February 2017. A total of 102 village clinics from 2 districts in northern Malawi were assigned to 1 of 6 clusters, which were randomized on the sequencing of the crossover from the control phase to the intervention phase as well as the duration of exposure in each phase. Children aged ≥2 months to <5 years who presented with acute illness were enrolled consecutively by health surveillance assistants. The primary outcome of urgent referrals to higher-level facilities was evaluated by using multilevel mixed effects models. A logistic regression model with the random effects of the cluster and the fixed effects for each step was fitted. The adjustment for potential confounders included baseline factors, such as patient age, sex, and the geographical location of the village clinics. Calendar time was adjusted for in the analysis. Results A total of 6965 children were recruited—49.11% (3421/6965) in the control phase and 50.88% (3544/6965) in the intervention phase. After adjusting for calendar time, children in the intervention phase were more likely to be urgently referred to a higher-level health facility than children in the control phase (odds ratio [OR] 2.02, 95% CI 1.27-3.23; P=.003). Overall, children in the intervention arm had lower odds of attending a repeat health surveillance assistant consultation (OR 0.45, 95% CI 0.34-0.59; P<.001) or being admitted to a hospital (OR 0.75, 95% CI 0.62-0.90; P=.002), but after adjusting for time, these differences were not significant (P=.07 for consultation; P=.30 for hospital admission). Conclusions The addition of e-CCM decision support by using smartphones led to a greater proportion of children being referred to higher-level facilities, with no apparent increase in hospital admissions or repeat consultations in village clinics. Our findings provide support for the implementation of e-CCM tools in Malawi and other low- and middle-income countries with a need for ongoing assessments of effectiveness and integration with national digital health strategies. Trial Registration ClinicalTrials.gov NCT02763345; https://clinicaltrials.gov/ct2/show/NCT02763345
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Affiliation(s)
- Griphin Baxter Chirambo
- Faculty of Health Sciences, Mzuzu University, Mzuzu, Malawi.,Malawi eHealth Research Center, University College Cork, Cork, Ireland
| | | | | | - Nicole Ide
- University of Washington, Seatle, WA, United States
| | | | | | | | | | | | | | | | | | - Tammy Tran
- Imperial College London, London, United Kingdom
| | | | | | | | | | - John O'Donoghue
- Malawi eHealth Research Center, University College Cork, Cork, Ireland.,Imperial College London, London, United Kingdom
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