This presentation was given at the technical mash-up meeting on "Mapping for Maternal and Newborn Health", hosted by ICS Integrare and the University of Southampton, with the support of the Norwegian Agency for International Development (NORAD) in Southampton (UK), 11-12th March 2013. Further details are available here http://integrare.es/?cat=33 The project described in this presentation looks at identifying local health system supply side constraints to scaling up maternal and newborn health care as well as estimating the marginal investment needed to expand coverage and uptake of services. By Steeve Ebener, Gaia Geosystems.

1. Investing the marginal dollar for
MNH: Geographic accessibility
analysis in five countries
Steeve Ebener
Gaia GeoSystems
Investing the marginal dollar Southampton,
for MNH: Geographic Accessibility Analysis in five countries
|
Southampton, March 11th, 2013 th
March 11 , 2013

2. Context - Investing the marginal dollar
for MNH
• Operationalizing the UN Secretary General’s
Joint Action Plan for women and children’s
health,
• Undertaken to inform policy discussions on how
to optimize or target the spending of the
marginal dollar for maternal health at country
level,
• Examine the infrastructure requirements for
scaling up coverage of institutional delivery with
skilled attendance.
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

3. Context - The Tanahashi framework
Target population who do not
Effectiveness Coverage contact services
Contact Coverage
…
Geographic aspect
Acceptability Coverage
Process of service
Accessibility Coverage
provision
Availability Coverage
TARGET POPULATION
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

4. Approach – Geography and GIS
Geography
GIS
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

5. Approach – Geography and GIS
Buffers Network Surface Spider
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

6. Tool – AccesMod (History)
2002: Start of the activity within the context of the of a cost-effectiveness
analysis
2003: Need to develop an automated module. First results obtained
through the application of the extension developed for ArcView
2004: Decision on the name for the extension: AccessMod. First publication
based on the use of AccessMod (ESRI health user conference)
2005: Release of version 2.1
2008: Release of version 3.0 (anisotropic version for Arcview 3.2)
2012: Release of version 4.0 (for ArcGIS 9.3.1) in the context of
the Investing the marginal dollar for Maternal and
Newborn Health project
10 years of development and use!
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

7. Tool – AccesMod (Download)
Freely accessible for ArcView 3.2 and ArcGIS 9.3.1:
• Through the WHO web site (currently updated):
http://www.who.int/kms/initiatives/accessmod/en/ind
ex.html
• ArcGIS online:
http://www.arcgis.com/home/index.html (search for
AccessMod)
Currently working at identifying sources of funding to
generate a version that would run under ArcGIS 10
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
|
Southampton, March 11th, 2013

8. Maximum
travel time
To
From
Processing
Order
New health
facility
information
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
|
Southampton, March 11th, 2013

9. WHO MNH project – Analysis
Country covered: Burkina Faso, Cambodia, Laos, Malawi and Rwanda
(+ Philippines)
Type of infrastructures: BEmOC and CEmOC
Analytical steps:
1. Physical accessibility to EmOC: Proportion of births taking place within a given
travel time to the nearest BEmOC or CEmOC
2. Comparison between the physical accessibility analysis and data on actual service
utilization (all facilities for BeMOC, C-sections for CEmOC)
3. Accessibility coverage: Estimate the health system capacity that would be
required to reach universal coverage for all the births located within 2 hours
travel time from the nearest EmOC and initiate the policy dialogue with countries
4. Cost analysis: Define a scenario to scale up the existing coverage capacity of the
EmOC network currently in place to reach universal coverage over the all country
and estimate the corresponding cost for this scaling up
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
|
Southampton, March 11th, 2013

10. WHO MNH project – Example of
implementation in Cambodia
Input data - GIS
Location EmOC Admin boundaries Hydro network Road network
DHS clusters DEM Births distribution Landcover
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

11. WHO MNH project – Example of
implementation in Cambodia
Input data - Statistics
At the national level
- Total and urban/rural Crude Birth Rate (CBR);
- Maximum expected travel speed on the different road types
At the sub national level
- Population by age groups and sex
- CBR (or fertility rate if CBR not available)
- Percentage of births delivered in a health facility (all level)
- Percentage of births delivered by C-section
At the cluster level (Household survey):
- Total number of non-assisted home deliveries
At the health facility level:
- For BEmoC (including CEmOC): Number of: nurses, midwifes and doctors
- For CEmOC: Number of functional operatory theaters, OB/GYN, medical worker
qualified to perform CS, medical worker qualified to perform anesthesiology
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

12. WHO MNH project – Example of
implementation in Cambodia
Input parameters – travelling scenario
Built areas, bare soils: 5 km/h
Low density vegetation: 4 km/h
Walking Low density vegetation: 3 km/h
Dense vegetation: 2 km/h
Prim nat roads: 80 km/h
Sec nat roads: 80 km/h
Prov roads: 60 km/h
Urban roads: 50 km/h
Rural roads: 40 km/h Taking a
vehicle
Based on WHO report and local
knowledge
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

13. WHO MNH project – Example of
implementation in Cambodia
Input parameters – Maximum travel time
1 hour
BEmOC
CEmOC
1st
Analysis
Other
2 hours
Analysis
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

14. WHO MNH project – Example of
implementation in Cambodia
Input parameters – Demand
BEmOC: 100 % of all births
CEmOC: 15 % of all births
Working at reaching Universal Coverage
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

15. WHO MNH project – Example of
implementation in Cambodia
Results of the first analysis (BEmOC andCEmOC)
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

16. WHO MNH project – Example of
implementation in Cambodia
Results of the second analysis (BEmOC and CEmOC)
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
|
Southampton, March 11th, 2013

17. WHO MNH project – Example of
implementation in Cambodia
Third analysis (2 hours travel time only): Step 1 – Use of AccessMod
Universal
coverage
within the
catchment
area
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

18. WHO MNH project – Example of
implementation in Cambodia
Third analysis (2 hours travel time only): Step 2 – Policy discussion
National norms
• BEmOC:
• Number of nurses, midwifes, doctors per X
number of births per year
• CEmOC:
• Number of OB/GYN, nurses, midwifes, medical
workers qualified to perform C-Sections, medical
workers qualified to perform anesthesiology as
well number of operatory theaters per X number of
births per year
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
|
Southampton, March 11th, 2013

19. WHO MNH project – Example of
implementation in Cambodia
Third analysis (2 hours travel time only): Step 2 – Policy discussion
Comparison between national norms and reality
Discussion on
the national norms
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

20. WHO MNH project – Example of
implementation in Cambodia
Fourth analysis (2 hours travel time only): Step 1 – Redistribution of capacities
Gap within 2 hours
travel time = 0
+7
Universal coverage
+9 within 2 hours
+6 (new staff)
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

21. WHO MNH project – Example of
implementation in Cambodia
Fourth analysis (2 hours travel time only): Complement of capacities
New facilities to cover
the births outside of 2
hours of travel time
Building, staff,
equipment,..
+
= Total cost to reach
universal coverage
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

22. WHO MNH project – Added value to
policy discussion
Inform current policy discussions at country and global
level by providing:
• Recommendations on health system output indicators
and benchmarks on EmOC;
• Evidence on current health system barriers to care
from the supply perspective and their implications for
expanding universal access to MNH services;
• Guidance on the relative financial resource
requirements for different scenarios aiming at
expanding access to, and use of, quality skilled care
at birth taking place in health facilities.
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

23. Strengths and Weaknesses of the
approach
Strengths:
• Good level of flexibility
• Goes beyond the usual accessibility analysis by including the
capacity (HR and equipment) component to measure
geographic coverage
• Results are easy to understand and facilitate policy
discussion
• Allows using MNH as a driver to improve the integration of the
geographic dimension in the HIS
Weaknesses:
• Data intensive exercise (data availability, quality, accuracy,..)
• Dependent on Esri’s technology (Arcview 3.2 or ArcGIS 9.3.1 +
Spatial analyst extension)
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

24. Expectations from the mash-up
• Learn about other approaches using GIS to
measure physical accessibility and geographic
coverage
• Have a chance to discuss few issues including:
• Methods to spatially distribute births at the
sub national level
• EmOC International/national norms (staff and
equipment )
• Find way to improve the current approach
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013

25. Thank You !
Karin Stenberg : stenbergk@who.int
Maliqui Blerta: maliqib@who.int
Steeve Ebener: steeve.ebener@gaia-geosystems.org
Investing the marginal dollar for MNH: Geographic Accessibility Analysis in five countries
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Southampton, March 11th, 2013