Accessmod Session 2

Introduction to GIS and AccessMod
2 -1
Session 2
Using GIS to measure and
analyze availability,
accessibility and geographic
coverage
Session 2 - Content
2 -2
Introduction
Methods and tools
Data issues
Data quality
Data accuracy
How to address these issues
Session 2 - Introduction
2 -3
Why measuring availability of care and

access to health care ?
Concept of "coverage"
Effective interventions
Effective coverage
A model of service access
Availability coverage
Accessibility coverage
Other components (not addressed)
Geographic coverage
Concluding words and questions

2 -4
Why measuring availability of care

and access to health care ?
Availability of care and access to health care are
important components of an overall health
system
Measuring accessibility to health care contributes
to a wider understanding of the performance of
this health systems and the identification of
potential gaps
This wider understanding allows for better

scaling up
planning of resources
Advocacy and decision making
Concept of "coverage"
2 -5
"Health service coverage is a concept

expressing the extent of interaction
between the service and the people
for whom it is intended, not being
limited to a particular aspect of
service provision, but ranging over
the whole process..."
(Tanahashi 1978).
Effective interventions
2 -6
Effective in this context does not refer to the

specific health impact of the intervention.
Effective coverage of the population is a
measure of the proportion of the population

who fully comply with a recommended
treatment regime.
For example, in the case of measurement of a
TB/DOTS programme, we should be concerned

with the proportion of TB patients who have
completed the entire course of treatment
Effective coverage
2 -7
The proportion of the population in need of an

intervention who have received an effective
intervention. Sometimes the evaluation of
service quality is included in this dimension.
The key to measurement of effective coverage is
to determine what constitutes an effective
intervention.
The measurement of effective coverage, as an
intermediate goal, is expected to link health
system performance measurement more directly
to managerial practices and decision- making
process at local, regional and national levels.
Source : Tanahashi, 1978 and Background paper for the Technical Consultation on Effective Coverage of Health Systems. World Health
Organization 2001.
2 -8
SERVICE DELIVERY GOAL
Effectiveness Coverage
Process of service provision

Target population who do not
contact services
Contact Coverage
Acceptability Coverage
Accessibility Coverage
Availability Coverage
TARGET POPULATION
Source: Tanahashi, T. (1978) "Health service coverage and its evaluation", Bulletin of the World Health
Organization, 56(2) : 295-303.
2 -9
SERVICE DELIVERY GOAL
Effectiveness Coverage
Process of service provision
Contact Coverage
Geographic coverage
Acceptability Coverage
Accessibility Coverage
Availability Coverage
TARGET POPULATION
Strong geographic dimension
2 -10
Availability coverage shows what resources are
available in what amount for delivering an intervention.

This might include: number of health facilities, number
of personnel, availability of technology (drugs,
equipment, etc.).
In other words, availability coverage relates the capacity

of a health system to the size of the target population.
Two ways of measuring availability coverage are
suggested:
The proportion of people for whom sufficient resources and

technologies have been made available.
The ratio of resources to the total population in need.
The proportion of facilities that offer specific resources, drugs,
technologies, etc.
Offer
Source : Tanahashi, 1978 and Background paper for the Technical Consultation on Effective Coverage of Health Systems. World Health
Organization 2001.
2 -11
Examples of measure:
nbr of nurses by inhabitants
nbr of hospitals by district
frequency of drug stock out
...
2 -12
Accessibility coverage measures how accessible
resources are for the population. The resources might

be available but inconveniently located, therefore
hindering physical access.
The distance from a health care provider seems to be a

very strong factor of accessibility.
Another factor of accessibility related to distance and
transportation facilities is time. The travel time to a
health facility and the waiting time to see a health
professional seem to be well associated with
consumers perception of accessibility of services.
Concern the demand side
Source : Tanahashi, 1978 and Background paper for the Technical Consultation on Effective Coverage of Health Systems. World
Health Organization 2001.
2 -13
percentage of the population living
within 5 km from the nearest facility
number of patient having to travel
more than 1 hour to reach care
Spatial distribution of the prevalence population

and of the ART patient compare to the location of
the ART sites
45.00
Axis
X: travel time expressed in
minutes
Y: percentage of total
considered population
40.00
% of total considered population
35.00
ART
patients
30.00
Curves
25.00
20.00
15.00
Prevalence
population
10.00
5.00
0.00
0-1
1-2
2-3
3-4
4-5
5-6
Travel time (hours)
2 -14
Example of spatial
distribution of the
prevalence population
according to the travel
time to the nearest ART
site (model)
6-7
7-8
>8
Example of spatial
distribution of the ART
patients according to the
travel time they took in
the reality (survey)
Other components (not addressed)
2 -15
Acceptability coverage measures the proportion of
people for whom services are acceptable. Even if

resources are available and accessible, they may not
be used if they are not acceptable to the population.
Acceptability includes affordability, in the first place,
as well as non-pecuniary factors such as cultural
acceptability, beliefs, religion, gender, type of facility,
neighbourhood of facility, etc.
Contact coverage measures the proportion of the
population who have had contact with a health service
provider. It is similar to utilization of services. For
health interventions that require a one-time action,
contact coverage may be virtually equivalent to
effective coverage. For other interventions,
effectiveness requires several contacts with a health
care provider.
Source : Tanahashi, 1978 and Background paper for the Technical Consultation on Effective Coverage of Health Systems. World
Health Organization 2001.

2 -16
Combining availability and

accessibility coverage: "geographic
coverage":
Availability looks at how the offer is spatially
distributed without considering if this offer is
physically accessible
Accessibility looks at how physically accessible a
service is to the population without considering if
the offer would be enough to cover the demand
Geographic coverage
Percentage of the prevalence population located within a given
travel time (e.g. 1,2,5, hours) of the nearest ART site taking
into account the patient coverage capacity of each site.
Travel time
Prevalence
population
covered (size)
% of the total
prevalence
population
Within 1 hour
120'000
52
Within 2 hours
145'000
63
+ 11 %
Within 3 hours
190'000
82
+19 %
Within 9 hours
190'000
82
+0%
Within 10
hours
190'000
82 %
+0%
increase in
coverage
Reach the maximum

coverage capacity of the
care delivery system
Use for scaling up !

2 -17
Spatial distribution
of the population being
not covered
Concluding words
Complexity
Data Accuracy
Spatial Modelling
geographic
coverage
Spatial Analysis
accessibility
coverage
Thematic Mapping
availability
coverage
Need for appropriate methods and tools
Questions ?
2 -18
Data Quality
Session 2 Methods and tools
2 -19
Geographic Coverage
Concluding words and

questions
Availability coverage (method)
2 -20
Survey instrument which integrates a

"Geo" component
Health facility or upper level
Need to standardize the collection of
the geographic component
Notion of Signature Domain
(Minimum set of field
to uniquely identify
an object)
Well established
data collection,
cleaning and
validation
protocols
Availability coverage (tool)

Example: Service Availability and Readiness
Assessment (SARA)
The Service Availability and
Readiness Assessment
(SARA) is a health facility
assessment tool designed
to assess and monitor the
service availability and
readiness of the health
sector and to generate
evidence to support the
planning and managing of a
health system
http://www.who.int/healthinfo/systems/sara_introduction/en/
2 -21
Availability coverage (tools)

Limitations: location and borders
Same availability coverage (e.g nbr of

health facility by district) !
Consider this surface as a closed system !
2 -22
2 -23
Limitations: level of desegregation

Number of infected people / ART patient by full time physician
Country population: 11'272'219 (wt Likoma)

ART sites: 103 (101 mapped)
Nbr of full time Physicians: 96
Country level prevalence data:
Total nbr of people infected: 1'572'907
Nbr of patients under ART: 81'632
At the country level:
16'350 people infected by 1 full time physician
850 patients under ART by full time physician
2 -24
Limitation: level of desegregation

At the country level:
16'350 people infected by 1 full time physician
850 patients under ART by full time physician
At the regional level:

Limitations: level of desegregation
At the district level:
Number of infected peoples
Number of patients under ART
Depends on the level of desegregation !

2 -25
2 -26
Limitations: others
Survey or census = snap shot in

time while the health care
delivery system is dynamic
Should move towards a maintained
health facility registry
Mostly looking at public facilities

importance of the private
facilities for certain
interventions (e.g.
HIV/AIDS)
potential sensitivities
Accessibility coverage (methods)
2 -27
2 types of measure:
distances
travel time
4 main methods:
Buffers
Network
Surface
Spider
2 -28
Distance versus travel time

peoples are better at estimating time than
distances
time is a more comparable measure (e.g. between
countries) than distances
distance can be derived, to some extent, from
geography while time is dependent on the
transportation media, condition of the patient and
other factors such as climate,...
the level of emergency when needing to receive
care is measure in time not in distance
...
All of this advocate in the favor of using time
and not distance for measuring accessibility
2 -29
Need:
geographic location of the considered
health facilities
maximum travel time considered for
reaching the health facility =>
distance (speed)
a GIS software allowing to draw a
buffer around each facility and
measure the population located in
each of them
Main advantage:
easy to implement once we have the location of
the facilities
Buffers
Major limitations:
only realistic in flat areas and where everybody is
traveling by feet ! Does not take barriers into
account
2 -30
Network
Need:
health facilities
reaching the health facility
the road network
a GIS software able to perform
network analysis and link each
population with the facilities
Main advantage:
realistic in countries where most of the
population use the roads (bus, car, motorcycle,..)
Major limitation:
Does not cover areas outside of the existing road
network
2 -31
Surface
Need:
health facilities
reaching the health facility
travel time distribution grid
a GIS software to draw catchment
areas based on the travel time
distribution grid
Main advantage:
allow to cover all the country and take different
travel scenario into account (walking, car,...)
Major limitation:
Requires several GIS layers to create the travel
time distribution grid
2 -32
Spider
Need:
geographic location of the point of
origin (e.g household)
geographic location of the visited
health facilities
a survey to have the information
about the length of travel (time) and
transportation media used
Main advantage:
gives the extend of the "real" catchment area
Major limitation:
Requires an important field data collection
exercise to get a representative picture
2 -33
Thiessen polygons
Not designed based on a maximum

distance or travel time
Need:
health facilities
a GIS software able to draw the
thiessen polygons
Main advantage:
indicates which facility is the closest from any point
in the country
Major limitation:
Does not take potential barriers to movements
into account (e.g. rivers).

Notion of catchment area
Definition: The area and population from
which a city or individual service
attracts visitors or customers. 1
Modeled versus "real" catchment area
2 -34
www.wikipedia.org
2 -35

Different models
Big difference in the results !
2 -36

Managing the overlaps !
example: 10 km buffer
Counting the same patient several

times !
Can't aggregate the data back to the
district level
2 -37

To, from and round trip
To = from
Round trip = to + waiting time + from
Will produce different catchment areas
2 -38

Isotropy versus anisotropy
Accessibility coverage (tools)
2 -39
SIGEpi
ESRI
products
and ext. 1
...
Network
Analyst (ext.
to ArcView)
GRASS 2
...
AccessMod
SIGEpi
Several
extension to
ArcView 1
Health
Analyzer
Flomap
...
http://www.esri.com/
http://grass.itc.it/
www.healthsystems2020.org/files/628_file_HealthGIStoolkit.pdf
2 -40
Spider
Patient exit survey conducted in the

context of the WHO Equity project
1. Questionnaire
Unique ID for each facility (slide 2-19)
administrative unit in which the patient
lives
point of origin for each patient (home,
work,...)
transportation media used (car, feet,
bicycle, bus,...)
time taken to reach the facility
additional information (e.g. any facility
closer ?)
855 patients after cleaning
2 -41
Spider

2. GIS layers
Geographic location of each facility
(latitude/longitude)
Extension of the considered administrative
units (traditional authorities)
3. GIS software
ArcView 3.2
Spider script
2 -42
Spider

Results
100%
80%
Travel time by sex and wealth quintile
60%
40% 120
Travel time in minutes
20%
100
80
0%
60
Bicycle (own, hired)

Car (own, hired)
Public bus
Male
40
20
Walk
Female
0-30
31-60
61-120
121+
7%
15%
22%
27%
3%
2%
4%
5%
36%
46%
34%
21%
54%
37%
39%
48%
Poorest
20%
Q2
Q3
Q4
Richest
20%
Full
sample
2 -43
Spider

Results

Spider
Limitations
Survey = snap shot in time while the

health care delivery system is
dynamic => institutionalization
importance of the sample
representativity if this exercise can't
be applied to all the facilities
need to have the geographic location

of all the surveyed facilities + of the
place of origin
institutionalize the process (routine)
importance of the health facility registry
can be implemented in the electronic
medical record system if any
2 -44

Surface
Utrecht Univ.
WHO
($)
Freeware
Stand alone
Extension
2011
2012
Freeware
Point of origin,
destination, road
network
1
2 -45
2 tools presented here:
Health facility location, population,

landcover, roads, barriers (rivers,
lakes,..), DEM
http://flowmap.geog.uu.nl/
2 http://www.who.int/kms/initiatives/accessmod/en/index.html
2 -46
Surface
Flowmap was specifically

designed to handle:
Storing, displaying, and
analysis of spatial flow
patterns, (for instance commuter trips, trade flows,
and telephone calls);
Computing distances, travel times, or transport
costs using a transportation network map;
Modelling the market areas of existing or planned
facilities.
Main advantages:
standalone
limited number of data required
Major limitations:
limited number of parameters
taken into account
does not handle anisotropic
movements
2 -47
Surface
AccessMod has been

designed to :
analyze physical
accessibility
analyze the population coverage capacity of an
existing health facility network
provide potential solutions for scaling up the
existing network if necessary
Main advantages:
take a larger number of parameters
into account
consider different traveling
scenarios (walking, car, bicycle)
manage anisotropic movements
access to ArcView capacities
Major limitations:
not a stand alone application
require more input data
Geographic coverage (Methods)
Maximum
travel time
To
From
Processing
Order
New health
facility
information
2 -48
Concluding words
2 -49
Combining where patients are coming from

(survey) with the results of the model
Potential bypassing
confidentiality
quality of care
...
Potential gaps
2 -50
Combining where patients are coming from

(survey) with the results of the model
45.00
Axis
X: travel time expressed in
minutes
Y: percentage of total
considered population
40.00
% of total considered population
Concluding words
35.00
ART
patients
30.00
Curves
25.00
Example of spatial
distribution of the
prevalence population
according to the travel
time to the nearest ART
site (model)
20.00
15.00
Prevalence
population
10.00
5.00
0.00
0-1
1-2
2-3
3-4
4-5
5-6
6-7
7-8
>8
Example of spatial
distribution of the ART
patients according to the
travel time they took in
the reality (survey)
Travel time (hours)
The use of several method is often needed to

allow for the analysis
Concluding words
2 -51
Scaling up the existing network
Concluding words
in French !
http://www.ij-healthgeographics.com/
Questions ?
2 -52
Session 2 Data
2 -53
The issues
Data accuracy
Data quality
How to address these issues ?
The issues
Complexity
Data Accuracy
Data Quality
Spatial Modelling
geographic
coverage
Spatial Analysis
accessibility
coverage
Thematic Mapping
availability
coverage
Need high data accuracy and quality !

2 -54
Data accuracy
Logical accuracy
1.
a
.
B
A
B
A
Refers to the integrity of relationships among

geographic features. 1
the logical accuracy is respected between 1. and 2.
Positional accuracy
1.
a.
2.
b.
A
C
C
A
B C
Positional accuracy, in contrast, maintains

that the coordinates of features in the GIS
database are correct relative to their true
positions on the earths surface. 1
the positional accuracy is not respected between
1. (true position) and 2. (GIS database)
If positional accuracy is fulfilled, logical accuracy is

normaly ensured by the oposite is not true
1
2 -55
2..
b
http://unstats.un.org/unsd/publication/SeriesF/SeriesF_79E.pdf
Data accuracy
2 -56
Some real examples (positional accuracy)
! !!
Rivers
CSO
Survey Dpt.
DCW
Satellite image
NSO
Dedza district hospital
LATH
MOH
CDC
500 m
Data accuracy
2 -57
Some real examples (positional accuracy)
Roads
Population
Incompatibility
between layers
Rivers
Population
Data quality
2 -58
Completeness Refers to having all parts or elements; lacking

nothing; whole; entire; full:
A real example
Coverage under estimated !
Data quality
2 -59
Time stamp
Refers to the temporal representativity of the data
Example
2000
1950
1980
2008
will not produce coherent results !
2 -60
- ...
Protocol
Practices
- Scale, projection
Protocol
- Completeness
Standards
- Time stamp
Protocol
Standard
Recommendations
- Unique identifier
Recommendations
2 -61
Protocol
Protocol
Protocol
Data production chain

2 -62
Session 2 Strengthening of the

geographic component of the HMIS
The Challenges the example

of Malawi
Using health as the driver for
the change
A different approach the
example of Zambia
Current activities
Conclusion
The Challenges
2 -63
Survey Department
Survey Department
Forestry Department
Survey Department
Survey Department
Ministry of Health
National AIDS Council
Local Government
National Statistical Office
CDC
.....
Survey Department
National Road Authority
National Statistical Office
Prevalence
Coverage Capacity
GIS capacity and

technical expertise
All
Ministry of Health
NAC
CDC
UNAIDS
...
The Challenges example of Malawi

Question to the MOH:
"What are your needs in terms of geographic information and
GIS capacities to support HIV/AIDS monitoring, evaluation

and response in Malawi ?"
Answer:
1. How to ensure the compatibility with data
coming from other sectors
2. Assessment of training needs
3. Designing the training curriculum
4. Training of Assistant Statisticians in collecting
point data of new facilities and how to combine
with existing data base
5. Interpretation of data
2 -64
2-
Major observed issues:

- Existence of an important capacity, in terms of skills, hardware and
software in the country but dispersed among a large number of GIS
stakeholders making each of them very thin in terms of capacity,
- Very limited or even a complete lack of communication between
institutions producing health data and/or geographic information of
interest in public health (MOH, NAC, NGOs, Survey Department,
National Statistical Office (NSO),),
- The MOH is not participating in the development of the National
Spatial Data Infrastructure (NSDI) for the country,
- Lack of agreed upon data collection standards and protocols
- existence of many different coding schemes that are not
linked together,
- very limited integration of the time dimension
- Lack of awareness of the data, resources and GIS skills available in
the country (e.g. from the academic sector),
- Important competition for funding.
2 -66
Duplication of efforts for the creation of

datasets that are of questionable quality
Rivers
CSO
Survey Dpt.
DCW
Satellite image
Important limitations towards the application

of the accessibility and geographic coverage
GIS based methods
2 -67
Important number of lost opportunities

- collect by the NSO of the location of the health facilities and schools, in
the context of the 2008 population census without collaborating with
the Ministry of Health nor the Ministry of education
- nobody at the Ministry of Health knew that the University of Malawi
was giving a course on medical geography
Large park of specific hardware (e.g. large

size printer, GPS devices) which is not
frequently used
Leveraging the existing capacity and data
as well as improving the working
connection between the stakeholders
would benefit all and improve decision
making

2 -68
Using health as the driver for the

change
Access to care is a major public health concern in
any intervention (HIV/AIDS in Malawi)
Geography is one strong component

which influence access to care
Several compatible GIS layers are needed in
order to measure and analyse this component
The stakholders who manage these different
layers need to wok together in order to
improve data accuracy and quality and
benefit from each other resources
Improving data will allow more informed
decision making and therefore improve
access to care

2 -69
A different approach the example

of Oman
There is a Geographic dimension

to Risk
Biological
Technological
Natural
Societal
Population
Highest
Risk
Infrastructures
Capacity
Services
VRAM principle

2 -70

of Oman

of Oman
There is a
Geographic
dimension
to Risk
2 -71

2-

of Oman - SOEMIS
Providing the right information in the right
place at the right time
to protect and save lives as well as the
countrys investments

2 -73

of Oman Lessons learned (health)
Health Information System not ready to support
Emergency Management and conduct risk
assessments:
Lack of complete and up-to-date registries
(patients, health facilities, human resources,
laboratories, catchment areas)
Health data distributed among different databases
managed by different departments within MOH
MOH not using specific data standards (i.e. coding
scheme) and disconnected from the other sectors
Geographic and time dimensions not integrated in
the HIS
Health indicators to measure population
vulnerability at the sub national level not available

2 -74

Project provided a unique opportunity to:
Bring the different department using/needing
geographic information and GIS together
Start addressing the current gaps and
limitations in the HIS to support Emergency
Management and risk assessment (i.e. unique
patient ID)
Start integrating the geographic and time
dimensions in the HIS
Lead to the establishment of a task force to be
converted into a permanent MOH Committee on
Information Management and GIS (CIMGIS)

2 -75

No entity at the MOH dealing with Emergency
Management
Lack of institutional framework and clear mandate
among departments regarding Information
Management and GIS
Limited technical capacity to answer the growing
demand for geographic information and GIS
Emphasized the need to address the above for
the MOH to ensure its role as the lead agency
for the Health sector its own needs
Vision defined when it comes to geographic
information and GIS (have all the health
data/information on the map)
http://www.testvram.org/SOEMIS/REPORTS/MOH_VRAM_pilot_final_report.pdf
Conclusion
The challenge for public health in countries when it
comes to geographic information is mainly to:
- make sure that all the data necessary for the work is
accessible, compatible and of good quality (maintenance !)
- have access to the necessary skills, hardware and
software in order to insure the analysis of the data
standards, protocols, guidelines and practices
working connections and collaboration (skills,

hardware, software,..)
infrastructures (metadata portal) and training
skills directory
policies and funding
National Spatial Data Infrastructure (NSDI) !

2 -76
Conclusion
2 -77
What is an SDI ?
"A Spatial Data Infrastructure or SDI is the
technology, policies, standards, human
resources, and related activities necessary
to acquire, process, distribute, use,
maintain, and preserve spatial data"
An NSDI being a National Spatial

Data Infrastructure
Conclusion
2 -78
Benefits of an SDI/NSDI
- build data once and use it many times for many
applications
- integrate distributed providers of data: cooperative
governance
- allow for "place-based management"
- share cost of data creation and maintenance and
reduce the duplication of efforts
- support sustainable economic, social and
environmental development
- improve decision making by giving access to more, of
better quality and compatible information/data
Conclusion
2 -79
NSDIs should actually been build to solve real

problems (e.g access to care) and not necessarily
technical problems
Health can be the context which leads the
development of an NSDI
Health should be part of the NSDI effort
This process indirectly strengthen the
geographic component of the HMIS

Accessmod Session 2

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Introduction to GIS and AccessMod

Introduction to GIS and AccessMod

Introduction to GIS and AccessMod

Why measuring availability of care and

Introduction to GIS and AccessMod

Why measuring availability of care

This wider understanding allows for better

Advocacy and decision making

Introduction to GIS and AccessMod

"Health service coverage is a concept

Introduction to GIS and AccessMod

Effective in this context does not refer to the

measure of the proportion of the population

For example, in the case of measurement of a

TB/DOTS programme, we should be concerned

Introduction to GIS and AccessMod

The proportion of the population in need of an

SERVICE DELIVERY GOAL

Introduction to GIS and AccessMod

A model of service access

SERVICE DELIVERY GOAL

Introduction to GIS and AccessMod

A model of service access

Strong geographic dimension

Introduction to GIS and AccessMod

Availability coverage shows what resources are

available in what amount for delivering an intervention.

In other words, availability coverage relates the capacity

The proportion of people for whom sufficient resources and

Introduction to GIS and AccessMod

Introduction to GIS and AccessMod

Accessibility coverage measures how accessible

resources are for the population. The resources might

The distance from a health care provider seems to be a

Introduction to GIS and AccessMod

Spatial distribution of the prevalence population

Introduction to GIS and AccessMod

Travel time (hours)

Introduction to GIS and AccessMod

Other components (not addressed)

Acceptability coverage measures the proportion of

people for whom services are acceptable. Even if

Introduction to GIS and AccessMod

Combining availability and

Introduction to GIS and AccessMod

Reach the maximum

Use for scaling up !

Introduction to GIS and AccessMod

Introduction to GIS and AccessMod

Session 2 Methods and tools

Concluding words and

Introduction to GIS and AccessMod

Availability coverage (method)

Survey instrument which integrates a

Introduction to GIS and AccessMod

Availability coverage (tool)

Introduction to GIS and AccessMod

Availability coverage (tools)

Same availability coverage (e.g nbr of

Introduction to GIS and AccessMod

Availability coverage (tools)

Limitations: level of desegregation

Country population: 11'272'219 (wt Likoma)

Introduction to GIS and AccessMod