The 1978 Alma-Ata Declaration created a primary health care (PHC) revolution that embodied the principles of equity, social justice, and health for all. PHC “is the first level of contact of individuals, the family, and the community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process”. More than 30 years later, the tenets of Alma-Ata remain relevant. PHC has both the potential to accelerate the achievement of the Millennium Development Goals (MDG) and fulfill the “Health for All” doctrine of the Alma-Ata Declaration by providing acceptable, accessible, appropriate, and affordable health care.
Many challenges remain, however, to achieving the goal of “Health for All” and the MDGs. Health systems consistently contribute to widening inequities in health. Access to health care is still governed by the inverse care law: the availability of good quality medical care tends to be inversely related to the need for it.
Access to health care services is multidimensional. In this paper, we use the conceptual framework described by Peters et al.. The framework centers on the concept of quality of care and describes the following four dimensions (each of which has a supply and demand element): 1) Geographical accessibility – the physical distance or travel time between the service delivery point and the user; 2) Availability – the opportunity to access the right type of health care services when needed as well as having the appropriate type of service providers, materials, and equipment; 3) Financial accessibility – the relationship between the price of services and the willingness and ability of users to pay for those services, as well as protection from financial consequences of health expenses; and 4) Acceptability – the responsiveness of health service providers to the social and cultural expectations of individual users and communities. In this paper, we concentrate on the two dimensions that are spatial in nature: geographical accessibility and availability. In many parts of the developing world, factors that affect the availability of health services include: lack of infrastructure, medical equipment, and supplies; shortage of or inadequate drugs; lack of and unequal distribution of qualified health personnel; and weak capacity for planning, managing, and supervising human resources. Geographical accessibility presents an important barrier to accessing health services. Studies in developing countries have demonstrated that physical proximity of health services is strongly linked to primary health care utilization[6–11].
In terms of health system performance, the spatial elements of availability and accessibilty can be converted to availability and accessibility coverage. Availability coverage demonstrates what resources are available and in what amount for delivering services. The availability of such resources limits the maximum capacity of the service and thus determines the amount of service that can be provided to the target population. Availability coverage relates the capacity of the health system to the size of the target population. Accessibility coverage determines how physically accessible resources are for the population. Distance and time are both important factors of accessibility. The World Health Organization (WHO) recommends using travel time, rather than distance, to assess geographical accessibility. The vast differences in geography and transportation infrastructure amongst and within countries make measures of distance to health facilities difficult to compare. In the case of accessibility coverage, the maximum capacity of the service is limited by the number of people who can reach and use it.
Combining availability and accessibility coverage allows us to define spatial coverage and to analyze, concurrently, the physical accessibility of the supply and the adequacy of the supply to cover the demand. Spatial coverage simultaneously takes into account the location and the maximum coverage capacity of each health facility, the geographical distribution of the population, the landscape through which the patient needs to cross to reach the health facility, and the mode of transportation.
Despite the adoption of pro-poor health policies and interventions by sub-Saharan African governments, health inequities and inaccessibility to basic health interventions remains high. It is imperative for resource-constrained countries in sub-Saharan Africa to monitor trends in health equity and access to essential PHC interventions to make the most efficient use of available resources and target those whose needs are greatest.
Advances in Geographical Information Systems (GIS) have contributed to more effective analyses of some aspects of health systems. GIS has been used to assess health care needs; analyze access to health services and understand disparities in access among different groups; evaluate health care utilization and its geographical variations; plan and evaluate health services; and provide spatial decision-making support for health care delivery.
This study utilizes GIS to measure geographical accessibility and spatial coverage of the public health system at the primary level in the Western Province (WP) of Rwanda. The objectives of this study were to measure geographical accessibility, model spatial coverage of the existing primary health facility network, estimate the number of primary health facilities working under capacity and the population underserved in the Western Province of Rwanda.