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