We combined geographical information on area of residence and clinic use to monitor the impact of decentralised chronic care services on estimated patient travel time, illustrated by a case study of ART roll-out in Malawi. A marked reduction in both potential and actual travel time was observed. However, the methods also highlighted that a growing proportion of patients does not attend their nearest clinic, and patients are actually less likely to transfer to another clinic as more available.
This work had several limitations. We did not have direct information on transport type which prevented us from using a hybrid walking-public transport model as presented in Tanser et al.. The travel speeds across surfaces were estimated from literature and local expert knowledge. As is likely to be the case other settings, budgetary and logistical restrictions stopped us from conducting the necessary field experiments. Fortunately, the sensitivity analyses used in these methods showed that our results were robust to variations in assumed travel speeds. The travel time surface was made using a number of simplifications. Firstly, we did not include seasonality and the impact of rivers being easy to cross during the dry season, and often impossible to cross during the rains. However most “track” journeys are parallel to the rivers, which run perpendicular to the tarmac road, and then along the road, so the effect of rivers would be limited. Altitude was left out as well, but as >98% of the population lives on the lakeshore or the plains, we feel this is a reasonable step to take. Using centre point of villages rather than the exact location of households reduces the precision of the estimates. Some villages can be quite spread out, especially further away from the main roads. However, village-level estimates are reasonable for the purposes of the analyses presented here. It is possible that ART patients systematically misreport where they live (to claim closer residence to a preferred clinic), but we have no evidence of this. We assumed an average travel time for each surface, although it is possible that some people choose to walk alongside the tarmac rather than travel with a minibus, particularly for shorter distances. This means that our estimated travel times could be slightly underestimated for those individuals.
These data included 4 clinics in 1 rural district, but these methods can easily be expanded to include a larger area and time span. The methodological framework can be generalised to other settings, where patient data on area of residence can be collected during clinical visits to fit with public resources that have GPS-coordinates available, e.g. through census enumeration areas, as is the case in Malawi. Clinic locations are available at central registries.
These methods allowed us to study the process of decentralisation of health services in a rural district in sub Saharan Africa, and visualise how it affected patient travel time. The strong reductions in potential and actual travel time, accompanied by increasing numbers of new patients starting ART, illustrate the value of decentralisation for getting patients started on therapy. Our approach also identified patients who are not attending their nearest clinic and how their behavior changed as services continued to become decentralised.
Results from KwaZulu Natal showed how distance to nearest clinic was strongly correlated with uptake of ART, which seems to be confirmed by the increase in patients starting ART as more (decentralised) clinics opened. Some of the patients who do not attend their nearest clinic may wish to remain at the clinic where they initiated ART. As the initial clinics were located at the larger hospitals this preference may be related to the perceived level of available care (availability of CD4 counts or drugs for opportunistic infection) or the relative anonymity of a larger clinic. Qualitative research of ART uptake at Chilumba Rural Hospital suggests patients may wish to hide their status in their home village or seek care from a preferred clinician. A study in a Southern District found that barriers other than distance to clinic (e.g. fear of drug supply problems), were important reasons for TB patients not to start ART.
In Sub Saharan countries the question of how to deliver care that is widely needed in challenging settings is important, as ART services expand but resources reduce and decentralised care for other chronic conditions will also become more prevalent[4, 5]. Researchers and policy makers need tools to better understand how decentralised services impacts on patient care seeking behavior, including uptake, revision. The methods presented here provide useful tools to better understand the impact of decentralisation on patient’s travel time to clinic and should be used as a platform to address further questions.