Geographic barriers to establishing a successful hospital referral system in rural Madagascar

• Published in: BMJ global health Vol. 6; no. 12; p. e007145
• Main Authors: Ihantamalala, Felana Angella, Bonds, Matthew H, Randriamihaja, Mauricianot, Rakotonirina, Luc, Herbreteau, Vincent, Révillion, Christophe, Rakotoarimanana, Serge, Cowley, Giovanna, Andriatiana, Tsirinomen’ny Aina, Mayfield, Alishya, Rich, Michael L, Rakotonanahary, Rado J L, Finnegan, Karen E, Ramarson, Andriamanolohaja, Razafinjato, Benedicte, Ramiandrisoa, Bruno, Randrianambinina, Andriamihaja, Cordier, Laura F, Garchitorena, Andres
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd 01.12.2021; BMJ Publishing Group LTD; BMJ Publishing Group
• Series: BMJ Global Health
• Subjects: Algorithms; Climatic conditions; Developing countries; Emergency medical care; Emergency medical services; Emergency services; Environment and Society; Environmental Sciences; Estimates; geographic information systems; Geography; Global positioning systems; GPS; Health care access; Health facilities; health systems; Hospitalization; Households; Humanities and Social Sciences; Humans; Infrastructure; LDCs; Life Sciences; Madagascar; Medical referrals; Original Research; Population; Primary care; Public health; Referral and Consultation; Roads & highways; Rural areas; Rural health care; Rural Population; Santé publique et épidémiologie; Statistical models; Travel; Universal Health Insurance; Madagascar; Africa; geographic information systems; health systems; public health; Madagascar
• ISSN: 2059-7908; 2059-7908
• DOI: 10.1136/bmjgh-2021-007145

BackgroundThe provision of emergency and hospital care has become an integral part of the global vision for universal health coverage. To strengthen secondary care systems, we need to accurately understand the time necessary for populations to reach a hospital. The goal of this study was to develop methods that accurately estimate referral and prehospital time for rural districts in low and middle-income countries. We used these estimates to assess how local geography can limit the impact of a strengthened referral programme in a rural district of Madagascar.MethodsWe developed a database containing: travel speed by foot and motorised vehicles in Ifanadiana district; a full mapping of all roads, footpaths and households; and remotely sensed data on terrain, land cover and climatic characteristics. We used this information to calibrate estimates of referral and prehospital time based on the shortest route algorithms and statistical models of local travel speed. We predict the impact on referral numbers of strategies aimed at reducing referral time for underserved populations via generalised linear mixed models.ResultsAbout 10% of the population lived less than 2 hours from the hospital, and more than half lived over 4 hours away, with variable access depending on climatic conditions. Only the four health centres located near the paved road had referral times to the hospital within 1 hour. Referral time remained the main barrier limiting the number of referrals despite health system strengthening efforts. The addition of two new referral centres is estimated to triple the population living within 2 hours from a centre with better emergency care capacity and nearly double the number of expected referrals.ConclusionThis study demonstrates how adapting geographic accessibility modelling methods to local scales can occur through improving the precision of travel time estimates and pairing them with data on health facility use.