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THE GEOGRAPHY OF COVERAGE
Professor Wendy J Graham Immpact, University of Aberdeen
&Dr Sennen Hounton
UNFPA, New York
Presentation for Countdown Equity Working GroupWomen Deliver conference: June 7th 2010
The power of communication
2
% of deliveries by caesarean section: Burkina Faso 2003
<0.8% 08-1.5% >1.5%
3
Zimbabwe 2005
Zambia 2007
Nigeria 2008
Nepal 2006
Indonesia 2007
India 2005
Haiti 2005
Ghana 2008
Ethiopia 2005
Burkina Faso 2003
Brazil 1996
Bangladesh 2007
0 25 50 75 100
Capturing geographical inequities in coverage
Mean coverage index* for rural & urban areas
* Based on 8 maternal & child health services Rural Urban 4
Mean coverage index* & coverage gap across administrative regions
Somali
Afar
Oro
miya
Ben-Gum
z
SNNP
Amhara
Gam
bela
Harari
Dire D
awa
Harari
Addis Abeba
0
20
40
60
80
100Ethiopia 2005
Mean coverage index Coverage Gap
%
* Based on 8 maternal & child health services 5
Family planning needs satisfied
Antenatal care (4 or more visits)
Skilled attendant at delivery
DPT 3
Measles Vaccine
BCG Vaccine
Care seeking for pneumonia
Oral rehydration therapy and continued feeding
0 25 50 75 100
Ethiopia 2005
Geographical inequities by types of service
Rural Urban* Midwives, nurses, doctors
6
Tracking progress over space & time: deliveries with skilled attendants*,Ethiopia
National
2000 2005For urban population
within regions
2000 2005
For rural population within regions
2000 2005
% deliveries with skilled attendants
* Midwives, nurses, doctors
What are the reasons for geographical inequities?
8
Proportion of households in region in poorest category & mean coverage index: Ethiopia 2005
Somali
Afar
Gam
bela
Tigr
ay
Ben-G
umz
Oro
miya
Amha
ra
SNNP
Dire D
awa
Harar
i
Addis
Abeba
0
20
40
60
80
100
% Households poorest Mean coverage index
%
Inter-relationship with poverty
National % households poorest 9
Financial barriers
Urban
Rural
Coverage of acute care in urban & rural areas: caesarean section, Indonesia
≤ 1 km 1-2.5 km 2.5-5 km 5-7.5 km 7.5-10 km 10-15 km >15 km0
10
20
30
40
50
60
70
80
90
Deliveries in institutions: Burkina Faso, two rural districts, 2006
Source: Immpact
Physical barriers: distance% deliveries in health facilities
Distance to health facility11
Mid-Western Central WesternFar-Western Eastern0
20
40
60
80
100
Administrative regions
Mean coverage indexCoverage Gap
%
Mountain Hill Terrai0
20
40
60
80
100Physical areas
Mean coverage index Coverage Gap
%
Comparing coverage across administrative versus physical areas: Nepal 2006
12
What are the implications of geographical inequities?
13
Dipping-in-and-out of the health system: Nepal 2006
ANC 1 v
isit
Neonatal T
etanus
2+ Teta
nus In
ject
ions
ANC 4/4
+ visi
ts
Skille
d atte
ndant at d
eli...
Inst
itutio
nal deliv
eries
Postnata
l visi
t
Breast
feedin
g
DPT 1 d
ose
Full Vacc
ine
Contrace
ptive u
se0
20
40
60
80
100
120
Urban Rural National
% Continuum of care for woman, newborn and child across time
14
Series1
0 20 40 60 80 100 120
Facility cost (delivery room, supplies, etc)
Dollars per delivery (normal delivery)
Mountains/Hills
Policy implications
Geographic targeting of barriers to uptake of care: facility deliveries, Nepal 2005
Terrai
Source: Ensor et al, 2005; Immpact 15
Programme implications
INPUTS TO CARE
PROCESSES OF CARE:EFFECTIVE COVERAGE
OUTCOMES OF CARE
0
100
200
300
400
500
600
700
<5 5-19.9 20-39.9 40-59.9 60+
Distance in km
MM
R p
er 1
00
.00
0 li
ve b
irths
MMR
Maternal mortality by distance to district hospitals: Indonesia 2004-6
Source: Immpact (Banten Province)16
Data & research implications
• Data gaps: inputs; barriers to access; quality of care; outcomes
• Data-capture gaps: potential of technologies - GPS, mobile phones, PDAs
• Communication gaps: “clever” maps - overlaying inputs, processes & outcomes
17
The Geography of Coverage:
key messagesThe power of communication: maps & other visual presentations of geographical inequities in coverage can appeal to many different audiences.
Reducing barriers to timely access to quality care: geographical inequities highlight barriers of special relevance to childbirth & so to achieving MDG4 & 5.
Acknowledgements
With special thanks to:• Immpact colleagues at the University of Aberdeen:
Ann Fitzmaurice and Jacqui Bell• UNFPA for supporting parts of the analysis • Countdown to 2015 & Equity Working Group members
Thank you