Exploring country-wide equitable government health care facility access in Uganda

Abstract

Background: Rural access to health care remains a challenge in Sub-Saharan Africa due to urban bias, social determinants of health, and transportation-related barriers. Health systems in Sub-Saharan Africa often lack equity, leaving disproportionately less health center access for the poorest residents with the highest health care needs. Lack of health care equity in Sub-Saharan Africa has become of increasing concern as countries enter a period of simultaneous high infectious and non-communicable disease burdens, the second of which requires a robust primary care network due to a long continuum of care. Bicycle ownership has been proposed and promoted as one tool to reduce travel-related barriers to health-services among the poor.

Methods: An accessibility analysis was conducted to identify the proportion of Ugandans within one-hour travel time to government health centers using walking, bicycling, and driving scenarios. Statistically significant clusters of high and low travel time to health centers were calculated using spatial statistics. Random Forest analysis was used to explore the relationship between poverty, population density, health center access in minutes, and time saved in travel to health centers using a bicycle instead of walking. Linear Mixed-Effects Models were then used to validate the performance of the random forest models.

Results: The percentage of Ugandans within a one-hour walking distance of the nearest health center II is 71.73%, increasing to 90.57% through bicycles. Bicycles increased one-hour access to the nearest health center III from 53.05 to 80.57%, increasing access to the tiered integrated national laboratory system by 27.52 percentage points. Significant clusters of low health center access were associated with areas of high poverty and urbanicity. A strong direct relationship between travel time to health center and poverty exists at all health center levels. Strong disparities between urban and rural populations exist, with rural poor residents facing disproportionately long travel time to health center compared to wealthier urban residents.

Conclusions: The results of this study highlight how the most vulnerable Ugandans, who are the least likely to afford transportation, experience the highest prohibitive travel distances to health centers. Bicycles appear to be a "pro-poor" tool to increase health access equity.

Keywords: AccessMod 5.0; Accessibility analysis; Bicycles; Equity; Health care; Social determinants of health; Sub-Saharan Africa; Uganda.

Fig. 1

Study area map of Uganda with National Referral (NR) Hospital, Regional Referral (RR) Hospital, General Hospital, and Health Center (HC) locations in relation to Population Density

Fig. 2

A geographic representation of health care travel times for each health care level: a HC II, b HC III, c HC IV, d Hospital, e Regional Referral Hospital, f National Referral Hospital for the walking (1), bicycling (2), and driving (3) scenarios

Fig. 3

Statistically significant clusters of high (red) and low (blue) health care access within Uganda at a Parish level for the nearest health center

Fig. 4

Partial Dependence Plot for travel time in minutes to health clinic by population density for the walking scenario

Fig. 5

Partial Dependence Plot for travel time in minutes to health clinic by proportion of pixel in poverty for the walking scenario

Fig. 6

Partial Dependence Plot for minutes reduced by bicycle to health clinic by proportion of pixel in poverty

Fig. 7

Partial Dependence Plot for minutes reduced by bicycle to health clinic by population density

Fig. 8

Partial Dependence Plot for travel time in minutes to health clinic for the interaction between population density and poverty for the walking scenario

Fig. 9

Partial Dependence Plot for minutes reduced by bicycle to health clinic for the interaction between population density and poverty