Deployment of Rural Health Facilities in a Developing Country S.-U. Rahman; D. K. Smith The Journal of the Operational Research Society, Vol. 50, No. 9. (Sep., 1999), pp. 892-902. Stable URL: http://links.jstor.org/sici?sici=0160-5682%28199909%2950%3A9%3C892%3ADORHFI%3E2.0.CO%3B2-X The Journal of the Operational Research Society is currently published by Operational Research Society.
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Journal of the Operational Research Society (1999) 50, 892-902
# G I 9 9 9Operational Research Society Ltd. All rights reserved. 0160-5682199 $15.00 http:l/www.stockton-press.co.uk~jor
Deployment of rural health facilities in a developing country S-U
ah man'
and DK Smith2
' Unlvevsity of Westem Austr-alia, Perth, Australla and '~nivevsityof E x e t e ~UK This study describes the problem of finding suitable sites for additional health facilities in a rural area in Bangladesh. The objective is to improve the accessibility of people to the health care system given the existing set of facilities. As is frequently the case in developing countries, activities designed to develop and improve differing sectors of the infrastructure are poorly integrated and ill-coordinated. As a result, decision-makers may make independent and individual decisions about locating new set-vice facilities. Often, as has been the case in Bangladesh, these decisions are taken at a relatively low level, by officers of local government or by elected leaders in a region, or by a combination of these. In the absence of any formal analysis and generation of alternatives, the final decision may be made on political or pragmatic considerations. As a result the decisions are often far from optimal. Ultimately, better health care will enhance many sectors of a regional economy, and so the decision about where to invest in new or better resources is important for reasons over and above that of providing health care for the population. In this paper, the role of location-allocation modelling in developing countries is considered, and the specific Bangladeshi problem is considered as a maximal covering location problem which is solved by an efficient heuristic method. Keywords: developing country; location-allocation modelling; health service; maximum covering location problem; primary health care
Introduction Locational analysis is a widely used approach to planning where to place services and the types of service for regional development. One of the tools for locational analysis is quantitative location-allocation modelling. It provides a framework for investigating problems of accessibility to an infrastructure, such as health services, comparing the quality (in terms of efficiency) of previous locational decisions and generating alternatives such as suggesting more efficient systems or improving those that exist. The decision about where to locate different types of facility to provide health care is a widely occurring problem. Accordingly, health care is one of the most widespread applications of location-allocation modelling, - since it is a universal need, which must be provided throughout a nation, with demand (roughly) in proportion to the population. In the context of developing countries, locational decisions are generally taken locally by government officers or by local elected leaders or by both. In the absence of any f ~ r m a l analysis and generation of alternatives, the final decision Correspondence: Dr DK Sinith, School of~Watl~ematical Sciences, Universiv of Exeter: Exeter EX4 4QE, UK E-mail:
[email protected].~l~(lr
may be made on political or pragmatic considerations. As a result the decisions can very often be far from However, other studies have shown that when alternatives are generated after formal analysis and placed before the decision-makers, they will be ons side red.^'^ There is considerable evidence that access to health facilities is very difficult for rural people in developing countries. In 1997, it was estimated that less than 40% of the population in Bangladesh has access to basic health care.6 In recent years, Bangladesh, like many developing countries, has given high priority to the development of primary health care in order to extend coverage of health services in rural areas and improve overall national health. This involves two approaches:' deployment of more resources and appropriate technologies; effective utilization of available resources. While the Government of Bangladesh has been gradually increasing funding for health over the years, these enhanced allocations have not made significant changes to the facilities which are available. Clearly, the Government has limited total resources and cannot meet every need at the same time. Decision makers and health planners
S - U Rzhman and DK S~mih-Deployment of rural health facilities in a developing country 893
must therefore make effective use of what is available. This has been emphasised in a recent policy document called the Fifth Health and Population Program (1998-2003).~ It pointed out that 'simply increasing public spending. . .is not sufficient for achieving the objective of reaching and assisting the poor and vulnerable and addressing inequality'. Location-allocation modelling can play a significant role in making health facilities more accessible to the people and therefore can help make the most effective use of the available resources. In this study an attempt has been made to find optimal locations of two types of health facility in rural Bangladesh. These are Community Clinics (CC) and Health and Family Welfare Centres (HFWC). The location problems are considered as maximum covering location problems (MCLPS).~ The objective in a MCLP is to maximise the population who live within a given distance of a facility which provides health care using a fixed number of facilities. This study is divided as follows: the background of the study is given in the next section. There then follows a section describing briefly the area of Bangladesh which has been studied. The Government's health policy is discussed in the subsequent section. The next two sections provide locational analysis of the HFWCs and CCs respectively. The study ends with a brief conclusion of its main points.
Background In Bangladesh, a unit of local government is known as a 'thana'. Typically, a thana has a population measured in tens to hundreds of thousands. Each thana consists of about ten to fifteen 'Unions'. In 1993, the European Commission (EC) initiated the Thana Functional Improvement Pilot Project (TFIPP). The EC-sponsored project is providing assistance to the Ministry of Health and Family Welfare (MOHFW) of the Government of Bangladesh. Recently, the Govemnent, in conjunction with the World Bank, developed a comprehensive health policy to extend the coverage of the primary health care. The objective of the TFIPP is to develop an efficient and effective operational system so that the partnership of the Government and the World Bank can deploy a health service in the country. As its name implies, the TFIPP operates at the Thana level and below. The relationship between the Government, the World Bank, the EC and TFIPP is shown in Figure 1. The TFIPP consists of four filnctional units, which are worlung in an integrated manner in order to achieve its objective. The functional units are: 1. Training and communication
2. Public health 3. Management intervention
4. Operations research and social development (ORSD) unit
and Extension of
I
European Comm~sclon(EC)
I TFIPP (Pilot Pio:ectl
-
---+ Government of Bangladesh
---4
World Bank
t_
I MOHFW
Figure 1 Health policy development and i~nplementationbodies
in rural Bangladesh. The ORSD is the youngest unit among all and was formally formed in-1997. Since then it has developed as an integral part of the TFIPP. The unit has completed a number of studies aimed at understanding peoples' attitude towards the public health sew ice^,'^ investigating the relationship between poverty level, health service knowledge and utilisation of health service^,""^ and determining the effect of distance on the utilisation of ambulance^.'^ Based on these items of research, the ORSD unit has initiated hrther studies, each of which apply some kind of OR technique. These are listed in the appendix. The ORSD is making plans to ensure that there is an equitable and efficient system for the delivery of health facilities throughout the country. For some considerable time, the Government's national health policy has been based on a health care system wlth three levels of services from primary health care to specialised care. Primary health care includes treatment of common diseases, preventive and promotive health care at communitylvillage, union, and thana levels. The health delivery system at thana level and below consists of a Thana Health Complex (THC), Health and Family Welfare Centres (HFWCs) and Community Clinics (CCs). Figure 2 shows the administrative divisions at the national level and health facilities at each level. This study is concerned with the location of HFWCs and CCs at the union level and communitylvillage level respectively. The functions of these types of facilities are to deliver health services which are known as the Essential Services Package (ESP) to the mral population. There are five components of the ESP, Reproductive Health, Child Health, Communicable Disease Control, Limited Curative Care, and Behaviour Change Communication. Both HFWCs and CCs are meant to delivery these service components. However, the level of services would depend on the types of facilities. Table 1 describes the first four services. The fifth compo-
894 Journal of the Operational Research Society Vol. 50, No. 9
building effective community support for health seeking behaviour; changing the attitudes and behaviour of service providers to provide client centred services.
A
,,/ \,,,
D!s;r,ci
D~slilct
Secondary Care
Hosx;
rhand
Cnmmun~tyN~llage
Type of Cdre
Adiniri~strativeLevels
Community Clinic
ileairh Faclllry
Kote SHMCI1 - Speclallzed Hosp~taland Medlcal College Hosp~tal THC - Thana Health Complex HFWC - Healtii and Famll! Welfare Centre
Figure 2 Hierarchy of public health care system in Bangladesh.
nent, behaviour change communication, is an intervention programme which is aimed at: changing the attitudes and the behaviour of people to improve their health status;
Since the underlying plans are established by the national government, the European project has decided to act within them, rather than to propose any alternative ways of meeting the health needs in the country. Although the reasoning behind this decision has not been documented, it is evident from other studies of OR in development (and in many other contexts!) that the best progress is made when the framework for planning is familiar to those who will have to implement the solutions.
Study area profile The initial plan of this study was to deal with the problem of locating health facilities in three unions. The team encountered a problem which is common in developing countries, the problem of inadequate data. Therefore, the study concentrated on Tangail thana, where sufficient,
Table 1 Services meant to be provided by Community Clinics and Health and Family Welfare Centres in Bangladesh. Services Facili~~
Community clinic
Repr-oductive health
Registration of pregnant woman
Immunization
Obtain antenatal history
Management and prevention of pneumonia, diarrhea and night blindness Health promotion
Vaccination Iron supplementation Ante-natal care and post-natal care Family planning Breast feeding promotion Appropriate referral Health and family welfare centre
Child health
Conduct normal delivery
Immunization
Ante-natal care and post-natal care MR Adolescent health Family planning Management and prevention of sexually transmitted diseases and AIDS
Integrated management of sick children
Communicable disease control
Malaria, tuberculosis, leprosy, kalaazar, and intestinal worm control activities as per national guidelines
Limited care
First aid
Treatment of pain and other minor ailments Referral
Communicable disease control activities (tuberculosis, malaria, leprosy, filariasis etc.)
First aid
Treatment of common ailments Referral
S - U Rahman and OK Smth-Deployment of rural health facilities in a developing country
895
1.4% of the population aged 10 years and above are engaged in agriculture, business and manufacturing activities respectively. The basic means of transportation in the municipality areas of the thana are rickshaw (manual tricycle) and bicycle. The majority of the population travels to the service facilities and business centres on foot. The thana headquarters is connected with most of the union councils by kutcha (unmetalled) roads. The lengths of pucca (metalled) and kutcha (unrnetalled) roads in this area are 55 km and 480 km respectively. The villages were identified on a 1 : 62500-scaled map produced by the Land Survey and Settlement Office of the Government of Bangladesh. The network of roads and footpaths in the area was updated on the map with the help of the Head Surveyor at the office of Tangail thana. Each link on the network was identified and measured and these data were used to compute a 212 x 212 distance matrix using a shortest path algorithm. At present seven HFWCs and a number of private practitioners provide health care to the local people. There is already some general infrastructure, for education, trade and communication. The definition of villages used follows that of the Government, and the details of villages have been taken from official sources.14
Figure 3 Map of the study area.
reasonably reliable data had been collected. This is one of 11 thanas in Tangail district, situated towards the southwestern part of the district (Figure 3). Tangail thana consists of 11 unions and one municipality area. A river flows through the thana which isolates three unions on the west (Kakua, Hugra and Katuli unions) during the monsoon season. Most parts of these three unions are flooded then and even in the dry seasons there is no road network between villages. Therefore these three unions have been excluded from the study. Basic details of the current infrastructure in the area are given in Table 2. The thana has a total population of about 240000. The population density is 1130 people per sq. km (as compared with 605 for the nation). About 46% are less than 15 y of age. Literacy rates are: 35% for males and 18% for females. A recent activity classification indicates that 19%, 6% and
Government policy and location of health facilities Despite remarkable reductions in the incidence of disease and in mortality rates over the last two decades, the extent of ill health in Bangladesh remains considerable. Available data on health in Bangladesh indicate that there are extremely high levels of preventable illness.15 Communicable diseases are the main cause of mortality. Diseases of concern include: (i) infections such as cholera and diarrhoea, typhoid, tuberculosis, leprosy, tetanus, diphtheria, measles, whooping cough; and (ii) parasitic diseases like malaria, filariasis and worm infestations. It appears that diarrhoea1 diseases (watery and dysentery), and lung and respiratory diseases (including pneumonia, asthma and tuberculosis) are responsible for about 34% of total
Table 2 Services and facilities in the study area Sewices and facilities (number) Union
Magra Baghil Gala Danya Gharinda Karatia Silimpur Porabari Municipality Total
HFWC RD College High school Prirnavy school Madrasa Hathazar Post ofice Water suppLv Electricity (no of villages)
896 Journal of the Operational Research Society Vol. 50, No. 9
deaths. Among the causes of child mortality, diarrhoea is the most significant; it accounts for about a quarter of deaths among children under 5 years, tetanus is the next most important cause.I5 It is important to note here that most of the communicable diseases can be controlled through immunization programmes, health education and better management of diarrhoea1 diseases. There are the important components of primary health care (PHC). Since the independence of Bangladesh, the Government's policy has been to provide comprehensive health care, and has concentrated on provision for the rural population. The Govemment recognised the inadequacies of health care facilities and their inequitable distribution, and so the First Five-Year Plan (1973-78) and the Two-Year Plan (1978-80) initiated a rural infrastructure for comprehensive health services with the objective of providing primary health care for everyone. The Second (1980-85) and Third Five-Year Plan (1985-90) reflects the national objective of providing 'Minimum Care to All' in the short run. The Fourth Five-Year Plan (1990-95) reinforced the Government's co~l~rnitment of providing primary health care to evelyone. The scope of the proble~nof health provision is indicated by the continuing needs after a quarter of a century. In a recent document, the Government of ~ a n ~ l a d e s h , ' in conjunction with the World Bank, developed some policy guidelines as to how rural health facilities be deployed. These relate to physical accessibility and population coverage. Physical accessibility The Community Clinics (CC) must be accessible within half an hour travel-time. It is perhaps simpler, from the point of view of modelling, to think in terms of traveldistance rather than travel-time. In mral Bangladesh most people walk to service facilities. So, for most people, there is a direct correlation between time and distance. Therefore, the maximum travel-time was translated by TFIPP into a maximum travel distance. Many studies on location of facilities in developing countries have used these two, (almost) equivalent, metrics. Distance can be easily measured, and studies of the behaviour of patients allows this to be translated into a travel time. It must be remembered that in an agricultural community, attending a health centre means both the loss of income and the loss of time from one's land, which affects the whole family. In the case of CCs, the maximum travel distance (S) was considered to be 2 krn. However, in the analysis more than one such upper limit on travel-distance was considered in order to find its effect on the population coverage and number of facilities. The Government policy does not say anything about the maximum distance that a patient may travel to receive services from HFWC facilities. However, the policy says
that there will be one HFWC in each union. This information has been transformed to yield the maximum allowable distance between the HFWCs and villages by optimally solving several MCLPs (separately for each union), keeping the number of facilities (p) fixed and varying the maximum travel distance (S). It was found that for p = 1 and S = 4 km,it was possible to cover all the population in each union. Since the municipality is considered to be equivalent to two unions, MCLPs for this area were solved for p = 2 for locating the HFWCs. It was found that with p = 2, S = 4 km it was possible to cover all the population in the municipality area. Hence, in this study, values of S of 2 km and 4km were used for locating CCs and HFWCs respectively. There are 4500 unions in the country and about 2400 HFWCs in operation now. As has been indicated already, CCs and HFWCs are considered as the nucleus of primary health care in Bangladesh. Population coverage With respect to the level of coverage by one CC, the Government has suggested three service d e l i v e j options. These are:
1. One CC per 1500 population 2. One CC per 3000 population
3. One CC per 6000 population. The coverage issue was discussed amongst Govemment planners and decision-makers in a consensus building workshop, where the task was to identify the best service delivery option. However, no concrete suggestion came out as to which alternative option should be considered for implementation. With respect to HFWCs, it has been suggested that one HFWC will serve a population of about 25 000. It would be appropriate to argue that the coverage issue should not be looked at in isolation, rather be analysed in conjunction with the maximum traveldistance. Location of health facilities Where should the two types of health facility described above be located? In Bangladesh, as in many developing countries, there is a strong negative correlation between distance from a place where health provision is available and the rate of utilisation of the ~ervice.'~"'Patients and potential patients will not travel far to receive basic treatment, though they will travel further if their need is more serious. Accordingly, the location problem is more appropriately considered as a maximum covering location problem (MCLP) to try and ensure that as many people as possible are within a given distance of facilities. The MCLP is chosen rather than a p-median problem with maximum distance constraints because the latter would
S-U Rahman and DK Smth-Deployment of rural health facilities in a developing country 897
consider the whole population, including those who might be too far from a facility. In effect, one wishes to know what percentage of the population remains uncovered given that the best set of locations of facilities cannot cover the total population. The Government's policy of locating one HFWC in each union and one CC per 6000 (considered the maximum level of population coverage) will make a health care delivery system consisting of 10 HFWCs and 40 CCs for the study area. To try and locate the best sites for these, we have used the Teitz and art" method for facility location. Because the method is a heuristic, the algorithm was run five times for each value of p and S and the best solution taken.
2. The maximal covering location problem (MCLP) is to maximise:
subject to:
Location-allocation models There is an extensive literature on location-allocation models in planning. Most can be represented as integer programmes, although the size and structure of these frequently means that a heuristic approach is more suitable. In this study, there was only a finite set of possible sites for facilities, and the users of the facilities were assumed to be at a finite set of locations. These sites and locations could be regarded as nodes on a network, with arcs whose weights represented the distances between nodes, then the mathematical formulations will be: 1. The p-median problem is to minimise:
where x, = 1 if a facility is located at j; x, = 0 otherwise. y, = 1 if demand from i is covered by a facility; y, = 0 otherwise. Ni = (iidy < S } is the set of facilities which are eligible to provide cover to demand i S =maximal service distance. n , a,, d,, p are as before. This problem only has 2n zero-one variables, which makes it more suitable for large problems.
subject to: Locational eficiency
xij
