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Accessibility mapping of health facilities in rural Ghana
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Accessibility mapping of health facilities in rural Ghana ⁎
Fauster Agbenyoa, Abraham Marshall Nunbogua, , Alfred Dongzaglab a b
University for Development Studies, Wa Campus, Department of Planning, Post Office Box, UPW 3, Wa, Upper West Region, Ghana University of Nottingham, School of Geography, NG7 2RD Nottingham, United Kingdom
AR TI CLE I NF O
AB S T R A CT
Keywords: Accessibility Health facilities GIS Rural Ghana Wa West District
Despite collaborative efforts by government, CSOs and the private sector in the provision of health facilities in Ghana, a substantial proportion of communities in rural Ghana still have poor accessibility to basic health services. Using a mixed approach, this paper presents an overview of geographic accessibility to health care services in Wa West District. Semi-structured interviews were conducted with randomly selected 100 households to ascertain their perception on accessibility to health services. Based on the major means of transport to each level of health service, GIS was used to model communities accessibility to health facilities. The findings revealed that, three levels of health services – CHPS, Health Centres and District Hospital exist in Wa West District. Over 50% of communities were found to have high accessibility to CHPS compounds and Health Centres because of their widespread distribution. In contrast, only few communities (4%) have high physical access to District hospital. Poor conditions of roads were a major barrier in household’s accessibility to District hospital. The findings therefore underscore the need for an integrated and cross-sectoral approach to improve accessibility to health care services.
1. Introduction Health is a fundamental human right and a major area of social and political concern throughout the world. In the 1970s, recognition was given to the fact that poor health and poverty were mutually dependent (Peters et al., 2008). In this regard, governments in developing countries adopted the ‘Health-for-All’ strategy which was affirmed in the Alma Ata declaration in 1978 (Hall and Taylor, 2003). Despite the frantic efforts by governments and tremendous policy aids from the international community to improve health conditions, many people in developing countries tend to have less access to health services and go without healthcare (Atuoye et al., 2015; O’Donnell, 2007; Peters et al., 2008). The problem of access to healthcare in developing countries manifests in two folds. On the supply side, the provision of healthcare facilities, and in instances where the facilities are provided, quality and effective services from these facilities may be missing perhaps due to inadequate resources whilst on the demand side, people may not get access to health service from which they could benefit (Mooney, 1983). In practice, these two sides are obviously related. Accessibility, in the context of health planning has been defined in various ways (see Mooney (1983), Penchansky and Thomas (1981), Daniels (1982), Frenk and White (1992)). In a broader sense it encapsulates four dimensions of access: availability, geographical dimension which relates to physical location, affordability, and acceptability (O’Donnell, 2007; Peters et al., 2008). In its narrow sense, it refers to the ease with which people can reach each destination from their origin – geographic accessibility. Accessibility in this context includes geographic distance between origin and destination and distance in terms of time spent on reaching the next location. Levesque et al. (2013, pp. 8) also defined access to healthcare as ‘the opportunity to identify healthcare
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Corresponding author. E-mail addresses: [email protected] (F. Agbenyo), [email protected] (A. Marshall Nunbogu), [email protected] (A. Dongzagla).
http://dx.doi.org/10.1016/j.jth.2017.04.010 Received 30 November 2016; Received in revised form 20 February 2017; Accepted 14 April 2017 2214-1405/ © 2017 Elsevier Ltd. All rights reserved.
Please cite this article as: Agbenyo, F., Journal of Transport & Health (2017), http://dx.doi.org/10.1016/j.jth.2017.04.010
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Fig. 1. Levels of health care at the district level in Ghana: Adapted from MOH (2016, p. 10).
needs, to seek healthcare services, to reach, to obtain or use healthcare services, and to actually have a need for services fulfilled’. In this paper we acknowledge the multidimensional nature of access but concentrate on geographic access (accessibility) to health service. This is because the physical presence at a geographical location of a health facility marks the beginning of access of any kind to the facility. In rural Ghana, the condition of roads between dwelling units and health facilities is key to ensuring accessibility to healthcare services. According to Atuoye et al. (2015) and Galaa and Daare (2008), good transport system which is often a rarity in rural Ghana are not only determinants of people’s access to healthcare but also for the easy distribution of drugs and other supplies to health facilities and for timely referrals in emergencies. The motivation of this paper is therefore to assess communities’ accessibility to healthcare services in rural Ghana. In doing so, this paper analyses the spatial distribution of health facilities in Wa West District as a case, using ArcGIS 10.2 and also examines the challenges of transportation in Wa West District in relation to communities’ accessibility to healthcare services. This paper is organised into five sections. Section 2 presents the healthcare system at the district level in Ghana. Section 3 discusses the research setting and methods used. Section 4 presents the analysis of the study. The discussion and concluding remarks are presented in Section 5. 2. Healthcare system at the district level in Ghana The health system in Ghana is organized in five tiers. These are; Community-Based Health Planning and Services (CHPS) at the community level, health centres at the Sub-district level, district hospital at the District level, regional hospital at the Regional level and specialized/teaching hospitals at the National level. This review focuses on the first three levels as they all fall within the spatial coverage of the study district (Fig. 1). At the community level, the CHPS compounds constitutes the most basic level of healthcare services provision and function more to promote primary healthcare. The main aim is to promote the health of communities especially women and children in rural and remote areas. Every CHPS compound has Community Health Officers (CHOs) who act as resident nurses and are to follow clients to their homes and communities for healthcare delivery. The CHOs conduct health promotion and education in the community with the support of Community Health Volunteers (CHVs). They also provide outreach services to communities during immunization or for antennal and postnatal care. CHOs are provided with basic medicines and medical apparatus for primary healthcare while emergency cases are referred to the next level of health facility in the district. CHOs also supervise clients discharged from the other higher health facilities. Health centres at the Sub-district level represent the next level of healthcare delivery in the District. It is headed by a medical assistant and staffed with specialists in the areas of midwifery, laboratory services, public health, environmental, and nutrition. At this level, both preventive and curative services are provided by the health centers as well as out-reach services to the communities within their catchment areas. Health Centres also provide minor surgical services such as drainage and incision and refer severe health cases to the next level of care provision in the hierarchy. At the district level, the district hospital is the apex in healthcare delivery. District hospitals provide curative care, preventive care, out-patient and in-patient services, and health promotion in the district. The district hospital therefore provides the first level of comprehensive care in the district. The District Health Administration (DHA) provides supervision and management support to their sub-districts while the District Assemblies and Ministry of Health are responsible for the provision of healthcare facilities within the districts. Emergency cases in the district are catered for by the district hospital, with complications being referred to the regional 2
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hospital in Wa. Generally, district hospitals in Ghana are faced with inadequate ambulance fleet which makes it impossible for rural communities to access ambulance services (Adamtey et al., 2015). In Wa West District, there is only one functional ambulance vehicle which is not able to serve remote communities because of the poor condition of roads in the hinterlands and the inability of patients to pay for services rendered them.
3. Research setting and methodology 3.1. Study area The study is conducted in the Wa West District which is one of the eleven (11) districts in the Upper West Region of Ghana. The District was curved out of the Wa Municipality in 2004 with Wechiau as its capital. It lies approximately between longitudes 9º 40’ N and 10º 10’ N and also between latitudes 2º 20’ W and 2º 50’ W. The district shares Boundaries with Sawla-Tuna-Kalba District to the South, Wa Municipal to the East, Nadowli District to the North and to the West with Ivory Coast. The local economy of the District is agrarian with over 90% of its population being subsistence farmers (WWDA, 2014). The Ghana poverty and inequality report (2016) shows that Upper West Region records the highest poverty incidence in the country (Cooke et al., 2016). Within the Region, the Wa West District is classified as the poorest district, making it one of the poorest in the country with a poverty incidence of about 92.4 percent (GSS, 2014; GSS, 2015). Regarding the depth with which people live in inequality, Upper West Region still leads with the highest level of inequality and largest increase in inequality since the last two decades. This implies that rural districts such as Wa West lag behind in economic development and access to basic social services. The low socio-economic development of the district pushes people into undesirable poverty pockets. A poverty pocket can be seen as a zone or enclave which embodies a “critical minimum asset threshold, below which families are unable to successfully educate their children, build up their productive assets, and move ahead economically over time” (Carter et al., 2007 p. 837). Unfortunately, poor households or individuals are always entangled in poverty traps in which it is impossible for them to escape without external assistance (Barrett and McPeak, 2006). Within the District, there are three major road classifications which include trunk roads, feeder roads and tracks. The categorization is justified on the basis of motorability of the roads and its surface features, that is, the nature as well as the condition of the roads. The trunk roads are distinguished by tarred surfaces and have relatively low travel time compared to the feeder roads. Feeder roads are generally not tarred with several potholes. They are however, sometimes resurfaced by the Department of Feeder Roads and are motorable all-year round. Tracks constitute the major road network and help in ensuring mobility within the District. These roads are not motorable in the rainy season. Transport services play an important role in explaining why some communities are able to increase their consumption more than others (Jalan and Ravallion, 2002). Generally, road conditions are bad in the District and public transport runs less frequently. The commonest mode of travel to health facilities is by foot and transiting on bicycle (Atuoye et al., 2015). This may be a contributing factor to poverty and inequality as geographic isolation is highly correlated to poverty (Anderson and Broch-Due, 2000; Starkey and Hine, 2014).
3.2. Research design and methods The paper adopted the cross-sectional research design by eliciting data for the study at one point in time (Creswell, 2013). In assessing the spatial distribution of health facilities in the Wa West District, a Geo-Information System (GIS) software was used because of its functional capacity of measuring accessibility. There are several measures of analysing accessibility (see Baradaran and Ramjerdi (2001), Geurs and van Eck (2001), Halden et al. (2000), Handy and Niemeier (1997)). However, this study adopted, the network measure (also known as infrastructure based measures (Church et al., 2000)) and the simple distance measure. The network measure determines accessibility based on the availability of roads and public transport frequency and reliability (Church et al., 2000). Indicators normally incorporate travel time from an origin to a particular service and the frequency of bus passing an origin to a service point. This is not suitable when data quality is low (Ahlström et al., 2011). The simple distance measure defines accessibility as a straight-line distance between two locations. This measure is suitable where standards exist in terms of maximum travel distance or time to a facility (e.g. a person should reach a poly clinic within 15 min walking time). One advantage of using simple distance measure in accessibility analysis is that the data can easily be obtained and that the results can be interpreted easily. However, this measure ignores the transport, the traveler and the other temporal components of accessibility (Amer, 2007). In order to make these models robust, the researchers integrated local knowledge in the GIS by using interview data on accessibility in the study area. The network measure was used to measure access to District Hospital (which is the highest order health service in the district) using riding time and distance. The simple distance measure was also used to determine accessibility to other lower level health services in the district (health centres and CHPS compounds). This is done based on existing standards on the sphere of influence and the average walking time and distance a person should cover when accessing these facilities. The simple distance measure is used because many communities in the study area are served by footpaths and trucks which are not found in road network data. The simple distance measure therefore allowed for off-road modeling which is appropriate since off-road transport is common in the study area. On-road travelling is then calculated by the network methods.
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Table 1 The travel habits of respondents. Source: Survey Data, August, 2016. Type of Journey
Traveling to Hospital Traveling to Health Centre Traveling to CHPS
Means of Transport Walking
Motor Cycle
Bicycle
Public Bus
30 58 54
56 34 26
12 8 20
2 – –
3.3. Data collection methods Data on location of health facilities (CHPS, Health Centres and DH) and road network in the district was gathered for this study. These were mapped through field survey using GPS. As at August 2016, there were 26 CHPS compounds, 6 Health Centres and one District Hospital (DH). Data was also collected on acceptable range for accessing each of the health services. These were obtained through the review of health policies, national planning standards and interviews with health officials under each level of health services within the study area. For CHPS, it must be accessible within a radius of 5 km (GHS, 2002; MoH, 2016) and for Health Centres between 8 and 16 km radius (MEST, 2011). The DH is supposed to serve the entire district (MEST, 2011). The road dataset was collected from the Department of Feeder Roads and Town and Country Planning Department. Three classes of roads were identified. These are first class (trunk roads), second class (feeder roads) and third class (access routes or tracks). The third class roads were incomplete from our ground truthing and most access routes were not captured. Accessibility to the three levels of health facilities was modeled using the major means of transport which include walking, transiting on bicycle and motorcycle (see Table 1). Data on the major means of transport was also obtained through the household surveys and Focus Group Discussions (FGDs) carried out from July to September 2016. Focus group discussions were conducted in each of the 10 communities studied. Results of FGDs enabled the researchers to restructure the households’ questionnaire in line with research themes. The study area was divided into three strata (North, middle, and south) and three communities were selected from each stratum except the southern stratum. Four communities were selected from the southern stratum because of high concentration of communities relative to other strata. To get a fair picture of people’s perception on access to health services in the study area, quota sampling was used to allocate 10 households to each study community. Simple random sampling was used to select the households for the study. For qualitative data, one FGD was conducted in each study community. In total, the researchers administered 100 household survey questionnaires. Furthermore, 16 key informant interviews were conducted among health professionals in the district. Key informant interviews were moderated with a guide structured around the key issue of healthcare accessibility, transportation and mobility. 4. Accessibility modeling to health facilities The modeling was done using ArcGIS (10.2) software. The accessibility analysis was carried out at two levels. First was the accessibility analysis for each level of health service within the district and second an aggregate accessibility analysis for all the three levels of health services combined. The analyses for each level of health facilities are explained below. 4.1. CHPS compound and health centres From the household survey the major means of transport to the CHPS compounds and Health Centres (HCs) was by walking. A road-network-walking modeling was not appropriate because of incomplete road data set on access routes people travel from their homes to CHPS compounds and Health Centres. As a result, accessibility to CHPS and HCs were modeled using a straight line distance approach, also known as Euclidean analysis. Considering the small sizes of communities the distance calculated for each community is thus a good indicator of access for all households in the community. Euclidean analysis of CHPS compounds and HC was executed in ArcGIS and manually classified into three levels. In the case of the CHPS compounds the levels were; high accessibility zone (less than 5 km), moderate accessibility zone (5–8 km) and low accessibility zone which is more than 8 km. For the health centres, the high accessibility zone was less than 8 km away from the facility, moderate accessibility threshold was 8–16 km from the facility and low accessibility zone has a threshold of more than 16 km. 4.2. District hospital In respect of the GHS policy, every district is supposed to have one district hospital. The hospital in Wa West district is located in the district capital - Wechiau. From the survey, the major means of transport was motor/tricycle (refer to Table 1). A motorcycle/ tricycle network analysis was implemented in ArcGIS to have an appreciable understanding of the travel time away from the district hospital to communities. The motorcycle/tricycle travel speed on the three classes of road in the district was reported to be different based on interaction with community members. This was cross validated with reference to data gathered from community health officers who have been using motorcycles for outreach services. Though data was collected in the rainy season (from July to 4
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September) the authors elicited and used average speed across seasons (rainy and dry seasons) in order to get a holistic picture of accessibility in the area. For first class roads, the average distance per minute was 1.2 km, for second class road the average distance per minute was 0.8 km whilst that of third class was reported to be 0.5 km per minute. The network analysis was carried out and manually classified into three levels. High access zone areas were less than 30 min from homes, moderate access zone was 30–60 min ride away from the facility whilst the low access zone was above 60 min ride time from homes. In the network analysis, communities were defined by their centroids. In view of the small sizes of communities, the travel time calculated for each community is therefore a fair estimate for all households. It must however be mentioned that due to incomplete road dataset, some few communities did not have direct routes to the DH. In such instances the travel time to district hospital in the network analysis was based on the nearest route to the community. This implies that, the travel time calculated for those communities is shorter compared to they having direct linking routes to DH. 4.3. Aggregate accessibility A weighted overlay spatial analyst tool in ArcGIS (10.2) was used to generate a composite accessibility map from all three levels of health services. The weighted overlay tool overlays several raster layers using a common measurement scale and weighs each according to its importance (ArcGIS 10.2 help). Based on interaction with health officials, the relative influence/importance of district hospital, health Centres and CHPS compounds were rated as 55%, 30% and 15% respectively. A three-point measurement scale was applied – high accessibility, moderate accessibility and low accessibility. 5. Results 5.1. Respondents’ perspectives on accessibility in the study area The data gathered from the questionnaire administration provided a good foundation for the accessibility analysis. The data provided views of the communities on accessibility and transportation in general in the District. The survey results indicate that walking and the use of motorbike were the most important means of mobility in the study area (Table 1). Out of the 100 households interviewed, 51 percent of them owned motorbikes. Interestingly, ownership of motorbikes does not seem to correlate with the number of respondents who visit health facilities on motorbikes. A possible explanation is that community members borrow motorbikes from their neighbours when visiting a health facility. Public transport is the least frequent means of transport to health facilities because most communities only have access to trucks on Wechiau market days which occur ones in every six days. Walking is the most frequent means of accessing healthcare which is however dependent on the severity of the case. One respondent in Dogberi expressed that they had to walk for almost 3-hours to access a CHPS compound at Donye. These findings elucidate those of Atuoye et al. (2015) who reported that walking for more than 10 km to CHPS compounds is common in the study area because of the poor nature of roads. Similarly, a documentary entitled ‘dying to deliver’ by joy news reported that motorcycle is the commonest means of transport to the district hospital during emergencies (JoyNews, 2016). When asked about their major transportation problems, 28 percent of respondents stated that distance to health facilities was too far, 45 percent referred to the bad road conditions as the major transportation challenge. About 27 percent mentioned the unavailability of public buses in their communities. However, respondents attributed the unavailability of public transport to the bad conditions of the roads to their villages. Hence, bad condition of roads was ranked the most challenging transport problem by majority of the respondents. The survey identified distance and poor conditions of roads are the most important determinants of accessibility to health facilities. Another interesting finding is that women mostly access health facilities by walking. The reasons attributed to this are; 1. Women do not own motorbikes and in most cases cannot ride motorbike, 2. Women mostly prefer to travel in groups in order to share and discuss personal issues with colleagues, 3. Antenatal care (ANC) is considered a women affair and men usually do not accompany their women to ANC which compels them to walk since they mostly can not ride motorcycle. The use of mobile phones has significantly influenced travel decisions and access to health information in study communities. In communities with good telecommunication network, mobile phones are used to communicate with surrounding villages to arrange for transport during emergencies. Also, mobile phones provide a platform for community health nurses to communicate with clients and also schedule community ANC and PNC meetings. 5.1.1. Accessibility to CHPS At the community level, CHPS compounds are the first point of contact during ill health and they provide basic primary healthcare services. As illustrated in Fig. 2, about 95 percent of communities in the study district have high access to CHPS which per Ghana Health Service standards is about 5 km radius from the facility. This is made up of five major enclaves within the District namely, the Oli-Pela-Dabo enclave to the north-western part of the District, the Jambosi-Piisie-Vieri-Asse enclave, which cuts across the lower- northern part of the District and has the second largest spread of CHPS facilities, the Tegmetuo-Kpanfa enclave to the upper south-western part of the District, with least spread of the facility, the theKangba-Chaksi-Yuonuuri enclave to the south-eastern part of the district with the highest spread of the facility and finally, the Donye-Talawona enclave to the extreme south western part of the District with the second-but-one spread of the CHPS facility. This is followed by the moderate accessibility zones. This also includes the Mahotanga-Kuzia enclave to the northern part, the Doreguayiri-Buyiri enclave at the middle of the district, the Tokali enclave to the Upper south-western part and the Ponyimayiri-Buyiri to the lower south western corner of the district. The least is the 5
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Fig. 2. Accessibility to CHPS compounds in Wa West District.
population within the low accessibility zones. This is made up of the Eggu-Chabile-Kolomuu enclave to the northern part, the SiirooDadafuri enclave to the eastern part and the Kandeo-Dogbeti enclave to the south-western part of the District. It is evident from Fig. 2 and the analysis that follows that about 5 percent of the population of the district fall outside the Ghana Health Service 5 km radius high accessibility zone. In terms of access, ANC is a success story. Discussions with respondents revealed the benefits they derived from CHPS. Among the women, about 80 per cent of them reported at least 4 ANC attendances before delivery which is good when compared to WHO focused antenatal care model. World Health Organisation focused ANC (FANC) model is a four goal oriented approach which seeks to promote the overall health of mothers and babies through targeted assessment of pregnant women in four ANC visits (WHO, 2011). Antenatal care links women and their families with formal health systems and increases the chance of skilled delivery at birth. However, respondent added that the absence of transport is a great hindrance to accessing CHPS especially during emergency. Discussions with Community Health officers revealed that some communities are inaccessible in the rainy seasons due to the poor conditions of road. For such communities, home visits are done at the mercy of the rains. Some respondents recounted the challenges they encountered in moving sick persons to CHPS compounds which in most cases is the nearest health facility. “Though sometimes the nurse at the CHPS compound refers us to Wechiau, they provide some first aid during emergencies…you all know how I suffered with (name withheld) when he had convulsion. I had to tie him to my back with a cloth and rode a bicycle for the 8 km journey…by the time we got to the CHPS he was dead”( Male Discussant, Pela, August, 2016).
Participant indicated in an FGD that walking to the CHPS compound for treatment is challenging considering the distance they have to travel. They attributed their inability to access healthcare services frequently to the poor transportation system in the district. According to them, the health insurance scheme has improved their financial access to healthcare. For women, the free maternal healthcare program has further motivated them to visit CHPS and other health facilities for maternal healthcare. 6
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Fig. 3. Accessibility to health centres in Wa West District.
5.1.2. Accessibility to health centres Health centers represent the second level of healthcare service at the district level. As shown in Fig. 3, nearly 70 percent of the communities have high access to the HCs which is 5 km or less (less than 1.5 h walking distance). These high access zones are located around the six HCs spread across the District. They include the Eggu HC high access zone, Pase HC high access zone, the Beriyem HC high access zone, Lassie HC high access zone, Tanina HC high access zone and the Gurungu HC high access zone. The moderate access zones include the Pela-Siiru-Daku moderately accessible enclave located in the north-western corner of the district, Janko-GuoZonko area at the eastern part, the Piisie-Nakpala-Tokali-Donye area to the western part and Siiroo to the eastern part of the District. Only two communities, Dogberi and Talawona, can be described as physically inaccessible as these lie within the low accessibility zone in the District. It became apparent during discussions with health officers that HCs complement the services provided by CHPS compounds. It does so in two complementary ways. Firstly, it provides maternal and child healthcare services which constitute the core services provided by CHPS compounds. Secondly, HCs provide curative services to patients. Health centres therefore render more services as compared to the CHPS compounds. Therefore, for patient suffering from serious health problems HCs are by far the most preferred destination. Although not a major consideration, patients that choose to go to HCs attach more importance to the expected quality of treatment and drug availability. This appears that – even for mild health cases – a difference in travel behaviour can be expected for spatially rational patients. From respondents’ perspective, CHPS compounds do not provide treatment to some ailments and patients are mostly referred to HCs or to District hospital (DH) when it is a major case. In this regard, communities that are within the high access zones of CHPS 7
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Fig. 4. Accessibility to District Hospital in Wa West District.
compounds (refer to Fig. 2) are still somewhat deprived when it comes to quality of health services and availability of medication. Drawing on insight from Dogberi, it takes patients about 5-h to cover a distance of 25 km from the community to the nearest health centre in Gurungu. By simple distance measure, the nearest higher order health facility is the DH at Wechau, however, the local geography characterized by poor road network has made it hard to reach. A resident of Dogberi described the situation as follows; “For us in this community we are closer to our graves than to any health facility…the problem is that there are no roads as you have witnessed yourselves…we crossed rivers to get to Grungu. Donye CHPS compound is closer but the nurse there gives only paracetamol whatever your situation. Some of us are forced to treat ourselves and that brings complications sometimes” (Male discussant, Dogberi, July, 2016) Inferring from the above lamentation, it is evident that patients’ preference and expectation for quality healthcare are key determinants of their choice of facilities. However, this is not in all cases especially during emergencies. Sharing her experience, a community health volunteer revealed that pregnant women are sometimes compelled to rely on Traditional Birth Attendants for delivery because they are mostly the closest point of contact. 5.1.3. Accessibility to District Hospital Fig. 4 depicts the spatial accessibility to District Hospital (DH) in the Wa West District. It gives an excellent insight on how roads enable or act as constraints to healthcare access in rural communities. In the study area, accessibility using motor transport is common and provided the fastest means of access to the hospital since vehicular transport is mostly available on market days, which is once every six days. The most accessible communities are Wechau, Kandeo and Tegmatuore where few paved roads exist. Population in these communities reach the facility within 30 min ride time. On the average, communities in the moderate access zones, among which are Gushe, Piisie, Tanduori, Nakpala, Kpanfa, Tokali and Lassie, reach the DH within 1 h by motorbike. Although 8
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these communities on the average have access to the DH, accessibility can be reduced substantially in the rainy season. Majority of the communities are within the low access zone of the DH. People in these communities spend over 1 h-and-30-min travel time to access the facility. The very deprived communities (especially those in the far north) suffer from multiple deprivations in terms of access to the hospital and accompanied services that will improve their health. Interactions with health professionals revealed that more than 75 referred cases to the hospital are not honoured due to the difficulties encountered when visiting the hospital. Riding for more than 20 km to the hospital for healthcare is very common in deprived communities. For women in poor access areas, their lives are always at risk especially when in labour. At Pela, a woman narrated her ordeal when she was referred to the DH during labour as follows; “Every woman love children but in this community child birth is a matter of life and death because the hospital is far and the roads are not good…last month I was referred to the district hospital during my labour because I was over bleeding. There was no car so my husband had to carry me on his motorbike for this 20 km journey. I gave birth in the middle of the bush and was taken back home” (Female discussant, Pela, August, 2016). For the local folks in these far to reach communities, transport is a greater determinant of their health and livelihoods. Overall, as many as 30 per cent of respondents with mild healthcare problems opt for ‘over the counter’ drugs as first aid while waiting on the market day truck to visit the hospital. Communities can fluctuate between varied degrees of deprivation and well-being depending on the nature of their transportation system. By Euclidean distance, Ponyimayiri, which is about 11 km from Wechiau, is closer to the hospital and should have had better access to the facility than Piisie which is 13 km from the facility. However, due to the poor road network in the South-Western corridor of the District communities in this enclave have low access to the DH. Transport itself is not the desired product but a means to the DH. Therefore, in terms of access to DH, these communities are deprived. Better access to DH is therefore a pressing issue in the district. 5.1.4. Overall accessibility to health facilities This is a composite map indicating the general accessibility to health in the district. About 94 percent of communities have access to at least one health facility. However, as shown in Fig. 5, Wechiau and its surrounding communities like Kandeo and Tegmetuo constitute the functional region of the District. Functional region is a zone with high surface accessibility to higher order service which in this case is the DH. Within the District, communities like Dogberi, Ponyimayiri and Buyiri are classified as hard to reach communities. This means these communities have poor access to basic social services like healthcare as a result of the bad transport network in these areas. This reveals the processes that push these communities into undesirable poverty pocket. A poverty pocket in this context is seen as a zone within which families are unable to successfully access healthcare to enable them build up their productive assets, and move ahead economically over time. Unfortunately, these poor communities or households are entangled in poverty traps in which it is impossible for them to escape without external assistance. More productively, if health is viewed upon as prerequisite for socio-economic advancement: development in these communities is more likely to stagnate. For people in the deprived communities, spatial accessibility to health is therefore an element of real income which impacts on their well-being. 6. Discussions and conclusion Overall, the spatial distribution of health facilities depicted in this paper reflects the uniform population and distance-based planning standards for health care provision. Spatially, about 94 percent of communities are within the access zones of health facilities. Ideally, this implies that majority of the population would have access to health care services; however, this has proven to be unrealistic. The relatively high physical accessibility to HCs, that is nearly 70 percent of the communities with high access – within 5 km (approximately 1.5-h walking time) reach as against the 15–20 km radius (MEST, 2011), for instance, can be misleading when it comes to how these translate into health care service outcomes. This is because findings from the research depict an inverse relationship between distance and travel time to health facilities and access to health care. The bad road network and conditions have watered down the effectiveness of the appreciable distribution of HCs and the DH within the District. The situation is even worse in remote communities such as Dogberi which is cut off during rainy seasons. Populations in such communities are ‘captive walkers’ – walking is often the common means of transport when accessing health care. These barriers further aggravate the socio-spatial inequalities in remote areas. In this regard, the problem is not the distribution of health facilities within the District per se; it is rather the road network and condition to connect the communities to the healthcare facilities and service points. Besides, the 5 percent of the population of the District which falls outside the Ghana Health Service standard of 5 km radius CHPS compound (MoH, 2016; MEST, 2011) accessibility zone is indicative of a deficit because the Alma Ata declaration advocated for “Health-for-All” (Hall and Taylor, 2003). The problem in this particular case is inadequate provision of health facilities rather than the transportation system associated with otherwise high access pockets in the previous paragraph. Again, the findings on the effect of NHIS and free maternal health care on the physical accessibility of respondents and discussants are very significant. This brings together two key dimensions of accessibility namely the geographic accessibility which talks of availability of the facility and financial accessibility which refers to ability to pay (Levesque et al., 2013; O’Donnell, 2007; Peters et al., 2008). Aside the above, initial inferences indicate that low access to HCs-based health care services within the District deprives patients of quality health services and availability of medication. However, it is pertinent to note that it is this gap in physical access to higher order services within the District that calls for referrals from the lower order health service centres such as CHPS to higher order ones, 9
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Fig. 5. Functional region and poverty pockets.
in this case the HCs and the DH. In effect, it is argued in this paper that the high accessibility to CHPS compound-based health services makes up for the lower accessibility associated with HCs and DH within the District, particularly for those communities with good access roads. It is important to note that even though the HCs and DH have larger spheres of influence than the CHPS facilities on individual basis, when considered on aggregate CHPS compounds have larger spheres of influence. Thus, the existence of CHPS compound level health care services, which constitute the most basic healthcare services help to reduce the inaccessibility to health care services within the District. It is therefore recommended that bottlenecks which are preventing the effective health service delivery of this system be tackled to ensure the realization of its objectives. Finally, the higher accessibility associated with Piisie which is 13 km farther away from DH than Ponyimayiri, located 11 km closer to the DH brings out a major limitation of the Euclidian distance approach to accessibility analysis. To rectify this anomaly with the approach, a manual procedure was adopted to depict the true accessibility picture of the District. Transport itself is not an enddesired product but a means to the DH, as an end. Therefore, in terms of access to the DH, these communities are deprived. A better transportation system to ease accessibility to DH is therefore a pressing issue in the District. The paper reiterates that physical or geographical accessibility to health facilities and services goes beyond the siting of the facilities at a particular point but involves an integrated and cross-sectoral approach with special emphasis on the transportation system. Based on the findings we proposed community model for integrating community ambulance system into CHPS compounds. The first stage is identifying community influencers. These influencers could be prominent people from the community, chiefs and elders 10
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who can influence community’s actions. Next is the stage where community influencers are sensitized on the need for an emergency transportation fund. In the third stage, a broad based action plan is developed to rally the entire community into the process. Here, the community influencers are sufficiently empowered to lead community sensitization and education to rally the entire community to accept the project. The entire community also decides the amount each household should contribute either monthly or after harvest seasonally. At this stage also, influencers facilitate the formation of a governing committee which will be in charge of managing funds and negotiating with transport operators. Here, communities decide on which means of transportation would be favorable. They have some limited options to choose from; motorbikes, motor-king (tricycle), or private cars or private public transport (mini-bus). During health emergencies such as labor, the committee members in collaboration with close-relatives (in most cases the husband) of the pregnant woman, would commit the fund to bear the cost of transport to the next health facility. In this case, all expenses related to transport are often catered for by the fund, and the husband (or relation) is then given a period of time to repay the cost with some agreed interest. The local committee is responsible for the recovery of the loan, and they have the full backing of the chiefs and elders. Thus, the committee would not hesitate to use other means of debt recovery including summoning the debtor (or household) to the chief’s palace if the need be, to recover the money. Members who fail to repay the loan upon exhaustive persuasion could be surcharged and punished according to local community by-laws as agreed upon. The committee is entirely local, managed by the chiefs and other community influencers. This enhances a sense of belongings, hence promotes participation and sustainability. Though this paper focuses on physical barriers to health care, there are other socio-cultural and economic factors that affect households’ access to health care facilities in the district. Some possible factors include domestic workload, traditional practices that prevent women from early ANC visits, financial cost of assessing health care and the lack of trust in healthcare facilities. There is therefore the need for further research on how these factors other than physical barriers affects households’ access to health care. References Adamtey, R., Frimpong, J., Dinye, R.D., 2015. An analysis of emergency healthcare delivery in Ghana: lessons from ambulance and emergency services in Bibiani Anhwiaso Bekwai District. Ghana J. Dev. Stud. 12 (1–2), 71–87. Ahlström, A., Pilesjö, P., Lindberg, J., 2011. Improved accessibility modeling and its relation to poverty–A case study in Southern Sri Lanka. Habitat Int. 35 (2), 316–326. Amer, S., 2007. Towards Spatial Justice in Urban Health Services Planning: A Spatial-analytic GIS-based Approach using Dar es Salaam, Tanzania as a Case Study. Vol. 140 Utrecht University. Anderson, D.M., Broch-Due, V., 2000. The Poor are Not Us: Poverty and Pastoralism in Eastern Africa. James Currey Ltd. Atuoye, K.N., Dixon, J., Rishworth, A., Galaa, S.Z., Boamah, S.A., Luginaah, I., 2015. Can she make it? Transportation barriers to accessing maternal and child health care services in rural Ghana. BMC Health Serv. Res. 15 (1), 333. Baradaran, S., Ramjerdi, F., 2001. Performance of accessibility measures in Europe. J. Transp. Stat. 4 (2–3), 31–48. Barrett, C.B., McPeak, J.G., 2006. Poverty traps and safety nets. Poverty, Inequality and Development. Springer, US, pp. 131–154. Carter, M.R., Little, P.D., Mogues, T., Negatu, W., 2007. Poverty traps and natural disasters in Ethiopia and Honduras. World Dev. 35 (5), 835–856. Church, A., Frost, M., Sullivan, K., 2000. Transport and social exclusion in London. Transp. Policy 7 (3), 195–205. Cooke, E., Hague, S., McKay, A. 2016.The Ghana Poverty and Inequality Report: Using the 6th Ghana Living Standards Survey 2016. Retrieved July 7, 2016 from 〈https://www.unicef.org/ghana/Ghana_Poverty_and_Inequality_Analysis_FINAL_Match_2016〉(1).pdf. Creswell, J.W., 2013. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Sage. Daniels, N., 1982. Equity of access to healthcare: some conceptual and ethical issues. Milbank Meml. Fund Q. Health Soc. 51–81. Frenk, J., White, K.L., 1992. The Concept and Measurement of Accessibility. No. 534. Pan American Health Organizationpp. 842–855 (PAHO.Scientific Publication). Galaa, S.Z., Daare, K., 2008. Understanding barriers to maternal child health services utilisation in northern Ghana. J. Soc. Dev. Afr. 23, 2. Geurs, K.T., Ritsema van Eck, J.R., 2001. Accessibility measures: review and applications. Evaluation of accessibility impacts of land-use transportation scenarios, and related social and economic impact. Ghana Statistical Service (GSS), 2014. Ghana Living Standards Survey Round 6 (GLSS6): Main Report. Ghana Statistical Service, Accra. Ghana Statistical Service (GSS), 2015. Ghana Poverty Mapping Report. Accra, Ghana. Retrieved August 8, 2016 from 〈http://www.statsghana.gov.gh〉. Halden, D., McGuigan, D., Nisbet, A., McKinnon, A., 2000. Accessibility: Review of Measuring Techniques and Their Application. Scottish Executive, Central Research Unit, Great Britain. Hall, J.J., Taylor, R., 2003. Health for all beyond 2000: the demise of the Alma-Ata Declaration and primary health care in developing countries. Med. J. Aust. 178 (1), 17–20. Handy, S.L., Niemeier, D.A., 1997. Measuring accessibility: an exploration of issues and alternatives. Environ. Plan. A 29 (7), 1175–1194. Jalan, J., Ravallion, M., 2002. Geographic poverty traps? A micro model of consumption growth in rural China. J. Appl. Econom. 17 (4), 329–346. Joy News, 2016. Dying to deliver. myjoyonline.com. Retrieved February 2, 2017 from 〈https://www.youtube.com/watch?v=TrHdqUuRfMg〉. Levesque, J.F., Harris, M.F., Russell, G., 2013. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int. J. Equity Health 12 (1), 1. Mooney, G.H., 1983. Equity in healthcare: confronting the confusion. Eff. Health Care 1 (4), 179–185. Ministry of Health, 2016. National Community-Based Health Planning and Services Policy. Ghana, Accra. Ghana Health Service (GHS), 2002. The Community-Based Health Planning and Services initiative: Concepts and plans for implementation. Accra, Ghana. Ministry of Environment Science and Technology (MEST), 2011. Zoning guidelines and planning standards. Retrieved July 6, 2016 from 〈http://www.townplanning. gov.gh〉. O'Donnell, O., 2007. Access to healthcare in developing countries: breaking down demand side barriers. Cad. Saúde Públ. 23 (12), 2820–2834. Peters, D.H., Garg, A., Bloom, G., Walker, D.G., Brieger, W.R., HafizurRahman, M., 2008. Poverty and access to healthcare in developing countries. Ann. N. Y. Acad. Sci. 1136 (1), 161–171. Penchansky, R., Thomas, J.W., 1981. The concept of access: definition and relationship to consumer satisfaction. Med. Care 19 (2), 127–140. Starkey, P. Hine, J., 2014. Poverty and sustainable transport; How transport affect poor people with policy implications for poverty reduction. Retrieved August 12, from 〈https://sustainabledevelopment.un.org〉. Wa West District Assembly (WWDA), 2014. Medium Term Development Plan: 2014-2017. Wa, Ghana. World Health Organization, 2011. WHO statement on antenatal care. Geneva.
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Contents lists available at ScienceDirect
Journal of Transport & Health journal homepage: www.elsevier.com/locate/jth
Accessibility mapping of health facilities in rural Ghana ⁎
Fauster Agbenyoa, Abraham Marshall Nunbogua, , Alfred Dongzaglab a b
University for Development Studies, Wa Campus, Department of Planning, Post Office Box, UPW 3, Wa, Upper West Region, Ghana University of Nottingham, School of Geography, NG7 2RD Nottingham, United Kingdom
AR TI CLE I NF O
AB S T R A CT
Keywords: Accessibility Health facilities GIS Rural Ghana Wa West District
Despite collaborative efforts by government, CSOs and the private sector in the provision of health facilities in Ghana, a substantial proportion of communities in rural Ghana still have poor accessibility to basic health services. Using a mixed approach, this paper presents an overview of geographic accessibility to health care services in Wa West District. Semi-structured interviews were conducted with randomly selected 100 households to ascertain their perception on accessibility to health services. Based on the major means of transport to each level of health service, GIS was used to model communities accessibility to health facilities. The findings revealed that, three levels of health services – CHPS, Health Centres and District Hospital exist in Wa West District. Over 50% of communities were found to have high accessibility to CHPS compounds and Health Centres because of their widespread distribution. In contrast, only few communities (4%) have high physical access to District hospital. Poor conditions of roads were a major barrier in household’s accessibility to District hospital. The findings therefore underscore the need for an integrated and cross-sectoral approach to improve accessibility to health care services.
1. Introduction Health is a fundamental human right and a major area of social and political concern throughout the world. In the 1970s, recognition was given to the fact that poor health and poverty were mutually dependent (Peters et al., 2008). In this regard, governments in developing countries adopted the ‘Health-for-All’ strategy which was affirmed in the Alma Ata declaration in 1978 (Hall and Taylor, 2003). Despite the frantic efforts by governments and tremendous policy aids from the international community to improve health conditions, many people in developing countries tend to have less access to health services and go without healthcare (Atuoye et al., 2015; O’Donnell, 2007; Peters et al., 2008). The problem of access to healthcare in developing countries manifests in two folds. On the supply side, the provision of healthcare facilities, and in instances where the facilities are provided, quality and effective services from these facilities may be missing perhaps due to inadequate resources whilst on the demand side, people may not get access to health service from which they could benefit (Mooney, 1983). In practice, these two sides are obviously related. Accessibility, in the context of health planning has been defined in various ways (see Mooney (1983), Penchansky and Thomas (1981), Daniels (1982), Frenk and White (1992)). In a broader sense it encapsulates four dimensions of access: availability, geographical dimension which relates to physical location, affordability, and acceptability (O’Donnell, 2007; Peters et al., 2008). In its narrow sense, it refers to the ease with which people can reach each destination from their origin – geographic accessibility. Accessibility in this context includes geographic distance between origin and destination and distance in terms of time spent on reaching the next location. Levesque et al. (2013, pp. 8) also defined access to healthcare as ‘the opportunity to identify healthcare
⁎
Corresponding author. E-mail addresses: [email protected] (F. Agbenyo), [email protected] (A. Marshall Nunbogu), [email protected] (A. Dongzagla).
http://dx.doi.org/10.1016/j.jth.2017.04.010 Received 30 November 2016; Received in revised form 20 February 2017; Accepted 14 April 2017 2214-1405/ © 2017 Elsevier Ltd. All rights reserved.
Please cite this article as: Agbenyo, F., Journal of Transport & Health (2017), http://dx.doi.org/10.1016/j.jth.2017.04.010
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Fig. 1. Levels of health care at the district level in Ghana: Adapted from MOH (2016, p. 10).
needs, to seek healthcare services, to reach, to obtain or use healthcare services, and to actually have a need for services fulfilled’. In this paper we acknowledge the multidimensional nature of access but concentrate on geographic access (accessibility) to health service. This is because the physical presence at a geographical location of a health facility marks the beginning of access of any kind to the facility. In rural Ghana, the condition of roads between dwelling units and health facilities is key to ensuring accessibility to healthcare services. According to Atuoye et al. (2015) and Galaa and Daare (2008), good transport system which is often a rarity in rural Ghana are not only determinants of people’s access to healthcare but also for the easy distribution of drugs and other supplies to health facilities and for timely referrals in emergencies. The motivation of this paper is therefore to assess communities’ accessibility to healthcare services in rural Ghana. In doing so, this paper analyses the spatial distribution of health facilities in Wa West District as a case, using ArcGIS 10.2 and also examines the challenges of transportation in Wa West District in relation to communities’ accessibility to healthcare services. This paper is organised into five sections. Section 2 presents the healthcare system at the district level in Ghana. Section 3 discusses the research setting and methods used. Section 4 presents the analysis of the study. The discussion and concluding remarks are presented in Section 5. 2. Healthcare system at the district level in Ghana The health system in Ghana is organized in five tiers. These are; Community-Based Health Planning and Services (CHPS) at the community level, health centres at the Sub-district level, district hospital at the District level, regional hospital at the Regional level and specialized/teaching hospitals at the National level. This review focuses on the first three levels as they all fall within the spatial coverage of the study district (Fig. 1). At the community level, the CHPS compounds constitutes the most basic level of healthcare services provision and function more to promote primary healthcare. The main aim is to promote the health of communities especially women and children in rural and remote areas. Every CHPS compound has Community Health Officers (CHOs) who act as resident nurses and are to follow clients to their homes and communities for healthcare delivery. The CHOs conduct health promotion and education in the community with the support of Community Health Volunteers (CHVs). They also provide outreach services to communities during immunization or for antennal and postnatal care. CHOs are provided with basic medicines and medical apparatus for primary healthcare while emergency cases are referred to the next level of health facility in the district. CHOs also supervise clients discharged from the other higher health facilities. Health centres at the Sub-district level represent the next level of healthcare delivery in the District. It is headed by a medical assistant and staffed with specialists in the areas of midwifery, laboratory services, public health, environmental, and nutrition. At this level, both preventive and curative services are provided by the health centers as well as out-reach services to the communities within their catchment areas. Health Centres also provide minor surgical services such as drainage and incision and refer severe health cases to the next level of care provision in the hierarchy. At the district level, the district hospital is the apex in healthcare delivery. District hospitals provide curative care, preventive care, out-patient and in-patient services, and health promotion in the district. The district hospital therefore provides the first level of comprehensive care in the district. The District Health Administration (DHA) provides supervision and management support to their sub-districts while the District Assemblies and Ministry of Health are responsible for the provision of healthcare facilities within the districts. Emergency cases in the district are catered for by the district hospital, with complications being referred to the regional 2
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hospital in Wa. Generally, district hospitals in Ghana are faced with inadequate ambulance fleet which makes it impossible for rural communities to access ambulance services (Adamtey et al., 2015). In Wa West District, there is only one functional ambulance vehicle which is not able to serve remote communities because of the poor condition of roads in the hinterlands and the inability of patients to pay for services rendered them.
3. Research setting and methodology 3.1. Study area The study is conducted in the Wa West District which is one of the eleven (11) districts in the Upper West Region of Ghana. The District was curved out of the Wa Municipality in 2004 with Wechiau as its capital. It lies approximately between longitudes 9º 40’ N and 10º 10’ N and also between latitudes 2º 20’ W and 2º 50’ W. The district shares Boundaries with Sawla-Tuna-Kalba District to the South, Wa Municipal to the East, Nadowli District to the North and to the West with Ivory Coast. The local economy of the District is agrarian with over 90% of its population being subsistence farmers (WWDA, 2014). The Ghana poverty and inequality report (2016) shows that Upper West Region records the highest poverty incidence in the country (Cooke et al., 2016). Within the Region, the Wa West District is classified as the poorest district, making it one of the poorest in the country with a poverty incidence of about 92.4 percent (GSS, 2014; GSS, 2015). Regarding the depth with which people live in inequality, Upper West Region still leads with the highest level of inequality and largest increase in inequality since the last two decades. This implies that rural districts such as Wa West lag behind in economic development and access to basic social services. The low socio-economic development of the district pushes people into undesirable poverty pockets. A poverty pocket can be seen as a zone or enclave which embodies a “critical minimum asset threshold, below which families are unable to successfully educate their children, build up their productive assets, and move ahead economically over time” (Carter et al., 2007 p. 837). Unfortunately, poor households or individuals are always entangled in poverty traps in which it is impossible for them to escape without external assistance (Barrett and McPeak, 2006). Within the District, there are three major road classifications which include trunk roads, feeder roads and tracks. The categorization is justified on the basis of motorability of the roads and its surface features, that is, the nature as well as the condition of the roads. The trunk roads are distinguished by tarred surfaces and have relatively low travel time compared to the feeder roads. Feeder roads are generally not tarred with several potholes. They are however, sometimes resurfaced by the Department of Feeder Roads and are motorable all-year round. Tracks constitute the major road network and help in ensuring mobility within the District. These roads are not motorable in the rainy season. Transport services play an important role in explaining why some communities are able to increase their consumption more than others (Jalan and Ravallion, 2002). Generally, road conditions are bad in the District and public transport runs less frequently. The commonest mode of travel to health facilities is by foot and transiting on bicycle (Atuoye et al., 2015). This may be a contributing factor to poverty and inequality as geographic isolation is highly correlated to poverty (Anderson and Broch-Due, 2000; Starkey and Hine, 2014).
3.2. Research design and methods The paper adopted the cross-sectional research design by eliciting data for the study at one point in time (Creswell, 2013). In assessing the spatial distribution of health facilities in the Wa West District, a Geo-Information System (GIS) software was used because of its functional capacity of measuring accessibility. There are several measures of analysing accessibility (see Baradaran and Ramjerdi (2001), Geurs and van Eck (2001), Halden et al. (2000), Handy and Niemeier (1997)). However, this study adopted, the network measure (also known as infrastructure based measures (Church et al., 2000)) and the simple distance measure. The network measure determines accessibility based on the availability of roads and public transport frequency and reliability (Church et al., 2000). Indicators normally incorporate travel time from an origin to a particular service and the frequency of bus passing an origin to a service point. This is not suitable when data quality is low (Ahlström et al., 2011). The simple distance measure defines accessibility as a straight-line distance between two locations. This measure is suitable where standards exist in terms of maximum travel distance or time to a facility (e.g. a person should reach a poly clinic within 15 min walking time). One advantage of using simple distance measure in accessibility analysis is that the data can easily be obtained and that the results can be interpreted easily. However, this measure ignores the transport, the traveler and the other temporal components of accessibility (Amer, 2007). In order to make these models robust, the researchers integrated local knowledge in the GIS by using interview data on accessibility in the study area. The network measure was used to measure access to District Hospital (which is the highest order health service in the district) using riding time and distance. The simple distance measure was also used to determine accessibility to other lower level health services in the district (health centres and CHPS compounds). This is done based on existing standards on the sphere of influence and the average walking time and distance a person should cover when accessing these facilities. The simple distance measure is used because many communities in the study area are served by footpaths and trucks which are not found in road network data. The simple distance measure therefore allowed for off-road modeling which is appropriate since off-road transport is common in the study area. On-road travelling is then calculated by the network methods.
3
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Table 1 The travel habits of respondents. Source: Survey Data, August, 2016. Type of Journey
Traveling to Hospital Traveling to Health Centre Traveling to CHPS
Means of Transport Walking
Motor Cycle
Bicycle
Public Bus
30 58 54
56 34 26
12 8 20
2 – –
3.3. Data collection methods Data on location of health facilities (CHPS, Health Centres and DH) and road network in the district was gathered for this study. These were mapped through field survey using GPS. As at August 2016, there were 26 CHPS compounds, 6 Health Centres and one District Hospital (DH). Data was also collected on acceptable range for accessing each of the health services. These were obtained through the review of health policies, national planning standards and interviews with health officials under each level of health services within the study area. For CHPS, it must be accessible within a radius of 5 km (GHS, 2002; MoH, 2016) and for Health Centres between 8 and 16 km radius (MEST, 2011). The DH is supposed to serve the entire district (MEST, 2011). The road dataset was collected from the Department of Feeder Roads and Town and Country Planning Department. Three classes of roads were identified. These are first class (trunk roads), second class (feeder roads) and third class (access routes or tracks). The third class roads were incomplete from our ground truthing and most access routes were not captured. Accessibility to the three levels of health facilities was modeled using the major means of transport which include walking, transiting on bicycle and motorcycle (see Table 1). Data on the major means of transport was also obtained through the household surveys and Focus Group Discussions (FGDs) carried out from July to September 2016. Focus group discussions were conducted in each of the 10 communities studied. Results of FGDs enabled the researchers to restructure the households’ questionnaire in line with research themes. The study area was divided into three strata (North, middle, and south) and three communities were selected from each stratum except the southern stratum. Four communities were selected from the southern stratum because of high concentration of communities relative to other strata. To get a fair picture of people’s perception on access to health services in the study area, quota sampling was used to allocate 10 households to each study community. Simple random sampling was used to select the households for the study. For qualitative data, one FGD was conducted in each study community. In total, the researchers administered 100 household survey questionnaires. Furthermore, 16 key informant interviews were conducted among health professionals in the district. Key informant interviews were moderated with a guide structured around the key issue of healthcare accessibility, transportation and mobility. 4. Accessibility modeling to health facilities The modeling was done using ArcGIS (10.2) software. The accessibility analysis was carried out at two levels. First was the accessibility analysis for each level of health service within the district and second an aggregate accessibility analysis for all the three levels of health services combined. The analyses for each level of health facilities are explained below. 4.1. CHPS compound and health centres From the household survey the major means of transport to the CHPS compounds and Health Centres (HCs) was by walking. A road-network-walking modeling was not appropriate because of incomplete road data set on access routes people travel from their homes to CHPS compounds and Health Centres. As a result, accessibility to CHPS and HCs were modeled using a straight line distance approach, also known as Euclidean analysis. Considering the small sizes of communities the distance calculated for each community is thus a good indicator of access for all households in the community. Euclidean analysis of CHPS compounds and HC was executed in ArcGIS and manually classified into three levels. In the case of the CHPS compounds the levels were; high accessibility zone (less than 5 km), moderate accessibility zone (5–8 km) and low accessibility zone which is more than 8 km. For the health centres, the high accessibility zone was less than 8 km away from the facility, moderate accessibility threshold was 8–16 km from the facility and low accessibility zone has a threshold of more than 16 km. 4.2. District hospital In respect of the GHS policy, every district is supposed to have one district hospital. The hospital in Wa West district is located in the district capital - Wechiau. From the survey, the major means of transport was motor/tricycle (refer to Table 1). A motorcycle/ tricycle network analysis was implemented in ArcGIS to have an appreciable understanding of the travel time away from the district hospital to communities. The motorcycle/tricycle travel speed on the three classes of road in the district was reported to be different based on interaction with community members. This was cross validated with reference to data gathered from community health officers who have been using motorcycles for outreach services. Though data was collected in the rainy season (from July to 4
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September) the authors elicited and used average speed across seasons (rainy and dry seasons) in order to get a holistic picture of accessibility in the area. For first class roads, the average distance per minute was 1.2 km, for second class road the average distance per minute was 0.8 km whilst that of third class was reported to be 0.5 km per minute. The network analysis was carried out and manually classified into three levels. High access zone areas were less than 30 min from homes, moderate access zone was 30–60 min ride away from the facility whilst the low access zone was above 60 min ride time from homes. In the network analysis, communities were defined by their centroids. In view of the small sizes of communities, the travel time calculated for each community is therefore a fair estimate for all households. It must however be mentioned that due to incomplete road dataset, some few communities did not have direct routes to the DH. In such instances the travel time to district hospital in the network analysis was based on the nearest route to the community. This implies that, the travel time calculated for those communities is shorter compared to they having direct linking routes to DH. 4.3. Aggregate accessibility A weighted overlay spatial analyst tool in ArcGIS (10.2) was used to generate a composite accessibility map from all three levels of health services. The weighted overlay tool overlays several raster layers using a common measurement scale and weighs each according to its importance (ArcGIS 10.2 help). Based on interaction with health officials, the relative influence/importance of district hospital, health Centres and CHPS compounds were rated as 55%, 30% and 15% respectively. A three-point measurement scale was applied – high accessibility, moderate accessibility and low accessibility. 5. Results 5.1. Respondents’ perspectives on accessibility in the study area The data gathered from the questionnaire administration provided a good foundation for the accessibility analysis. The data provided views of the communities on accessibility and transportation in general in the District. The survey results indicate that walking and the use of motorbike were the most important means of mobility in the study area (Table 1). Out of the 100 households interviewed, 51 percent of them owned motorbikes. Interestingly, ownership of motorbikes does not seem to correlate with the number of respondents who visit health facilities on motorbikes. A possible explanation is that community members borrow motorbikes from their neighbours when visiting a health facility. Public transport is the least frequent means of transport to health facilities because most communities only have access to trucks on Wechiau market days which occur ones in every six days. Walking is the most frequent means of accessing healthcare which is however dependent on the severity of the case. One respondent in Dogberi expressed that they had to walk for almost 3-hours to access a CHPS compound at Donye. These findings elucidate those of Atuoye et al. (2015) who reported that walking for more than 10 km to CHPS compounds is common in the study area because of the poor nature of roads. Similarly, a documentary entitled ‘dying to deliver’ by joy news reported that motorcycle is the commonest means of transport to the district hospital during emergencies (JoyNews, 2016). When asked about their major transportation problems, 28 percent of respondents stated that distance to health facilities was too far, 45 percent referred to the bad road conditions as the major transportation challenge. About 27 percent mentioned the unavailability of public buses in their communities. However, respondents attributed the unavailability of public transport to the bad conditions of the roads to their villages. Hence, bad condition of roads was ranked the most challenging transport problem by majority of the respondents. The survey identified distance and poor conditions of roads are the most important determinants of accessibility to health facilities. Another interesting finding is that women mostly access health facilities by walking. The reasons attributed to this are; 1. Women do not own motorbikes and in most cases cannot ride motorbike, 2. Women mostly prefer to travel in groups in order to share and discuss personal issues with colleagues, 3. Antenatal care (ANC) is considered a women affair and men usually do not accompany their women to ANC which compels them to walk since they mostly can not ride motorcycle. The use of mobile phones has significantly influenced travel decisions and access to health information in study communities. In communities with good telecommunication network, mobile phones are used to communicate with surrounding villages to arrange for transport during emergencies. Also, mobile phones provide a platform for community health nurses to communicate with clients and also schedule community ANC and PNC meetings. 5.1.1. Accessibility to CHPS At the community level, CHPS compounds are the first point of contact during ill health and they provide basic primary healthcare services. As illustrated in Fig. 2, about 95 percent of communities in the study district have high access to CHPS which per Ghana Health Service standards is about 5 km radius from the facility. This is made up of five major enclaves within the District namely, the Oli-Pela-Dabo enclave to the north-western part of the District, the Jambosi-Piisie-Vieri-Asse enclave, which cuts across the lower- northern part of the District and has the second largest spread of CHPS facilities, the Tegmetuo-Kpanfa enclave to the upper south-western part of the District, with least spread of the facility, the theKangba-Chaksi-Yuonuuri enclave to the south-eastern part of the district with the highest spread of the facility and finally, the Donye-Talawona enclave to the extreme south western part of the District with the second-but-one spread of the CHPS facility. This is followed by the moderate accessibility zones. This also includes the Mahotanga-Kuzia enclave to the northern part, the Doreguayiri-Buyiri enclave at the middle of the district, the Tokali enclave to the Upper south-western part and the Ponyimayiri-Buyiri to the lower south western corner of the district. The least is the 5
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Fig. 2. Accessibility to CHPS compounds in Wa West District.
population within the low accessibility zones. This is made up of the Eggu-Chabile-Kolomuu enclave to the northern part, the SiirooDadafuri enclave to the eastern part and the Kandeo-Dogbeti enclave to the south-western part of the District. It is evident from Fig. 2 and the analysis that follows that about 5 percent of the population of the district fall outside the Ghana Health Service 5 km radius high accessibility zone. In terms of access, ANC is a success story. Discussions with respondents revealed the benefits they derived from CHPS. Among the women, about 80 per cent of them reported at least 4 ANC attendances before delivery which is good when compared to WHO focused antenatal care model. World Health Organisation focused ANC (FANC) model is a four goal oriented approach which seeks to promote the overall health of mothers and babies through targeted assessment of pregnant women in four ANC visits (WHO, 2011). Antenatal care links women and their families with formal health systems and increases the chance of skilled delivery at birth. However, respondent added that the absence of transport is a great hindrance to accessing CHPS especially during emergency. Discussions with Community Health officers revealed that some communities are inaccessible in the rainy seasons due to the poor conditions of road. For such communities, home visits are done at the mercy of the rains. Some respondents recounted the challenges they encountered in moving sick persons to CHPS compounds which in most cases is the nearest health facility. “Though sometimes the nurse at the CHPS compound refers us to Wechiau, they provide some first aid during emergencies…you all know how I suffered with (name withheld) when he had convulsion. I had to tie him to my back with a cloth and rode a bicycle for the 8 km journey…by the time we got to the CHPS he was dead”( Male Discussant, Pela, August, 2016).
Participant indicated in an FGD that walking to the CHPS compound for treatment is challenging considering the distance they have to travel. They attributed their inability to access healthcare services frequently to the poor transportation system in the district. According to them, the health insurance scheme has improved their financial access to healthcare. For women, the free maternal healthcare program has further motivated them to visit CHPS and other health facilities for maternal healthcare. 6
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Fig. 3. Accessibility to health centres in Wa West District.
5.1.2. Accessibility to health centres Health centers represent the second level of healthcare service at the district level. As shown in Fig. 3, nearly 70 percent of the communities have high access to the HCs which is 5 km or less (less than 1.5 h walking distance). These high access zones are located around the six HCs spread across the District. They include the Eggu HC high access zone, Pase HC high access zone, the Beriyem HC high access zone, Lassie HC high access zone, Tanina HC high access zone and the Gurungu HC high access zone. The moderate access zones include the Pela-Siiru-Daku moderately accessible enclave located in the north-western corner of the district, Janko-GuoZonko area at the eastern part, the Piisie-Nakpala-Tokali-Donye area to the western part and Siiroo to the eastern part of the District. Only two communities, Dogberi and Talawona, can be described as physically inaccessible as these lie within the low accessibility zone in the District. It became apparent during discussions with health officers that HCs complement the services provided by CHPS compounds. It does so in two complementary ways. Firstly, it provides maternal and child healthcare services which constitute the core services provided by CHPS compounds. Secondly, HCs provide curative services to patients. Health centres therefore render more services as compared to the CHPS compounds. Therefore, for patient suffering from serious health problems HCs are by far the most preferred destination. Although not a major consideration, patients that choose to go to HCs attach more importance to the expected quality of treatment and drug availability. This appears that – even for mild health cases – a difference in travel behaviour can be expected for spatially rational patients. From respondents’ perspective, CHPS compounds do not provide treatment to some ailments and patients are mostly referred to HCs or to District hospital (DH) when it is a major case. In this regard, communities that are within the high access zones of CHPS 7
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Fig. 4. Accessibility to District Hospital in Wa West District.
compounds (refer to Fig. 2) are still somewhat deprived when it comes to quality of health services and availability of medication. Drawing on insight from Dogberi, it takes patients about 5-h to cover a distance of 25 km from the community to the nearest health centre in Gurungu. By simple distance measure, the nearest higher order health facility is the DH at Wechau, however, the local geography characterized by poor road network has made it hard to reach. A resident of Dogberi described the situation as follows; “For us in this community we are closer to our graves than to any health facility…the problem is that there are no roads as you have witnessed yourselves…we crossed rivers to get to Grungu. Donye CHPS compound is closer but the nurse there gives only paracetamol whatever your situation. Some of us are forced to treat ourselves and that brings complications sometimes” (Male discussant, Dogberi, July, 2016) Inferring from the above lamentation, it is evident that patients’ preference and expectation for quality healthcare are key determinants of their choice of facilities. However, this is not in all cases especially during emergencies. Sharing her experience, a community health volunteer revealed that pregnant women are sometimes compelled to rely on Traditional Birth Attendants for delivery because they are mostly the closest point of contact. 5.1.3. Accessibility to District Hospital Fig. 4 depicts the spatial accessibility to District Hospital (DH) in the Wa West District. It gives an excellent insight on how roads enable or act as constraints to healthcare access in rural communities. In the study area, accessibility using motor transport is common and provided the fastest means of access to the hospital since vehicular transport is mostly available on market days, which is once every six days. The most accessible communities are Wechau, Kandeo and Tegmatuore where few paved roads exist. Population in these communities reach the facility within 30 min ride time. On the average, communities in the moderate access zones, among which are Gushe, Piisie, Tanduori, Nakpala, Kpanfa, Tokali and Lassie, reach the DH within 1 h by motorbike. Although 8
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these communities on the average have access to the DH, accessibility can be reduced substantially in the rainy season. Majority of the communities are within the low access zone of the DH. People in these communities spend over 1 h-and-30-min travel time to access the facility. The very deprived communities (especially those in the far north) suffer from multiple deprivations in terms of access to the hospital and accompanied services that will improve their health. Interactions with health professionals revealed that more than 75 referred cases to the hospital are not honoured due to the difficulties encountered when visiting the hospital. Riding for more than 20 km to the hospital for healthcare is very common in deprived communities. For women in poor access areas, their lives are always at risk especially when in labour. At Pela, a woman narrated her ordeal when she was referred to the DH during labour as follows; “Every woman love children but in this community child birth is a matter of life and death because the hospital is far and the roads are not good…last month I was referred to the district hospital during my labour because I was over bleeding. There was no car so my husband had to carry me on his motorbike for this 20 km journey. I gave birth in the middle of the bush and was taken back home” (Female discussant, Pela, August, 2016). For the local folks in these far to reach communities, transport is a greater determinant of their health and livelihoods. Overall, as many as 30 per cent of respondents with mild healthcare problems opt for ‘over the counter’ drugs as first aid while waiting on the market day truck to visit the hospital. Communities can fluctuate between varied degrees of deprivation and well-being depending on the nature of their transportation system. By Euclidean distance, Ponyimayiri, which is about 11 km from Wechiau, is closer to the hospital and should have had better access to the facility than Piisie which is 13 km from the facility. However, due to the poor road network in the South-Western corridor of the District communities in this enclave have low access to the DH. Transport itself is not the desired product but a means to the DH. Therefore, in terms of access to DH, these communities are deprived. Better access to DH is therefore a pressing issue in the district. 5.1.4. Overall accessibility to health facilities This is a composite map indicating the general accessibility to health in the district. About 94 percent of communities have access to at least one health facility. However, as shown in Fig. 5, Wechiau and its surrounding communities like Kandeo and Tegmetuo constitute the functional region of the District. Functional region is a zone with high surface accessibility to higher order service which in this case is the DH. Within the District, communities like Dogberi, Ponyimayiri and Buyiri are classified as hard to reach communities. This means these communities have poor access to basic social services like healthcare as a result of the bad transport network in these areas. This reveals the processes that push these communities into undesirable poverty pocket. A poverty pocket in this context is seen as a zone within which families are unable to successfully access healthcare to enable them build up their productive assets, and move ahead economically over time. Unfortunately, these poor communities or households are entangled in poverty traps in which it is impossible for them to escape without external assistance. More productively, if health is viewed upon as prerequisite for socio-economic advancement: development in these communities is more likely to stagnate. For people in the deprived communities, spatial accessibility to health is therefore an element of real income which impacts on their well-being. 6. Discussions and conclusion Overall, the spatial distribution of health facilities depicted in this paper reflects the uniform population and distance-based planning standards for health care provision. Spatially, about 94 percent of communities are within the access zones of health facilities. Ideally, this implies that majority of the population would have access to health care services; however, this has proven to be unrealistic. The relatively high physical accessibility to HCs, that is nearly 70 percent of the communities with high access – within 5 km (approximately 1.5-h walking time) reach as against the 15–20 km radius (MEST, 2011), for instance, can be misleading when it comes to how these translate into health care service outcomes. This is because findings from the research depict an inverse relationship between distance and travel time to health facilities and access to health care. The bad road network and conditions have watered down the effectiveness of the appreciable distribution of HCs and the DH within the District. The situation is even worse in remote communities such as Dogberi which is cut off during rainy seasons. Populations in such communities are ‘captive walkers’ – walking is often the common means of transport when accessing health care. These barriers further aggravate the socio-spatial inequalities in remote areas. In this regard, the problem is not the distribution of health facilities within the District per se; it is rather the road network and condition to connect the communities to the healthcare facilities and service points. Besides, the 5 percent of the population of the District which falls outside the Ghana Health Service standard of 5 km radius CHPS compound (MoH, 2016; MEST, 2011) accessibility zone is indicative of a deficit because the Alma Ata declaration advocated for “Health-for-All” (Hall and Taylor, 2003). The problem in this particular case is inadequate provision of health facilities rather than the transportation system associated with otherwise high access pockets in the previous paragraph. Again, the findings on the effect of NHIS and free maternal health care on the physical accessibility of respondents and discussants are very significant. This brings together two key dimensions of accessibility namely the geographic accessibility which talks of availability of the facility and financial accessibility which refers to ability to pay (Levesque et al., 2013; O’Donnell, 2007; Peters et al., 2008). Aside the above, initial inferences indicate that low access to HCs-based health care services within the District deprives patients of quality health services and availability of medication. However, it is pertinent to note that it is this gap in physical access to higher order services within the District that calls for referrals from the lower order health service centres such as CHPS to higher order ones, 9
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Fig. 5. Functional region and poverty pockets.
in this case the HCs and the DH. In effect, it is argued in this paper that the high accessibility to CHPS compound-based health services makes up for the lower accessibility associated with HCs and DH within the District, particularly for those communities with good access roads. It is important to note that even though the HCs and DH have larger spheres of influence than the CHPS facilities on individual basis, when considered on aggregate CHPS compounds have larger spheres of influence. Thus, the existence of CHPS compound level health care services, which constitute the most basic healthcare services help to reduce the inaccessibility to health care services within the District. It is therefore recommended that bottlenecks which are preventing the effective health service delivery of this system be tackled to ensure the realization of its objectives. Finally, the higher accessibility associated with Piisie which is 13 km farther away from DH than Ponyimayiri, located 11 km closer to the DH brings out a major limitation of the Euclidian distance approach to accessibility analysis. To rectify this anomaly with the approach, a manual procedure was adopted to depict the true accessibility picture of the District. Transport itself is not an enddesired product but a means to the DH, as an end. Therefore, in terms of access to the DH, these communities are deprived. A better transportation system to ease accessibility to DH is therefore a pressing issue in the District. The paper reiterates that physical or geographical accessibility to health facilities and services goes beyond the siting of the facilities at a particular point but involves an integrated and cross-sectoral approach with special emphasis on the transportation system. Based on the findings we proposed community model for integrating community ambulance system into CHPS compounds. The first stage is identifying community influencers. These influencers could be prominent people from the community, chiefs and elders 10
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who can influence community’s actions. Next is the stage where community influencers are sensitized on the need for an emergency transportation fund. In the third stage, a broad based action plan is developed to rally the entire community into the process. Here, the community influencers are sufficiently empowered to lead community sensitization and education to rally the entire community to accept the project. The entire community also decides the amount each household should contribute either monthly or after harvest seasonally. At this stage also, influencers facilitate the formation of a governing committee which will be in charge of managing funds and negotiating with transport operators. Here, communities decide on which means of transportation would be favorable. They have some limited options to choose from; motorbikes, motor-king (tricycle), or private cars or private public transport (mini-bus). During health emergencies such as labor, the committee members in collaboration with close-relatives (in most cases the husband) of the pregnant woman, would commit the fund to bear the cost of transport to the next health facility. In this case, all expenses related to transport are often catered for by the fund, and the husband (or relation) is then given a period of time to repay the cost with some agreed interest. The local committee is responsible for the recovery of the loan, and they have the full backing of the chiefs and elders. Thus, the committee would not hesitate to use other means of debt recovery including summoning the debtor (or household) to the chief’s palace if the need be, to recover the money. Members who fail to repay the loan upon exhaustive persuasion could be surcharged and punished according to local community by-laws as agreed upon. The committee is entirely local, managed by the chiefs and other community influencers. This enhances a sense of belongings, hence promotes participation and sustainability. Though this paper focuses on physical barriers to health care, there are other socio-cultural and economic factors that affect households’ access to health care facilities in the district. Some possible factors include domestic workload, traditional practices that prevent women from early ANC visits, financial cost of assessing health care and the lack of trust in healthcare facilities. There is therefore the need for further research on how these factors other than physical barriers affects households’ access to health care. References Adamtey, R., Frimpong, J., Dinye, R.D., 2015. An analysis of emergency healthcare delivery in Ghana: lessons from ambulance and emergency services in Bibiani Anhwiaso Bekwai District. Ghana J. Dev. Stud. 12 (1–2), 71–87. Ahlström, A., Pilesjö, P., Lindberg, J., 2011. Improved accessibility modeling and its relation to poverty–A case study in Southern Sri Lanka. 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Access to healthcare in developing countries: breaking down demand side barriers. Cad. Saúde Públ. 23 (12), 2820–2834. Peters, D.H., Garg, A., Bloom, G., Walker, D.G., Brieger, W.R., HafizurRahman, M., 2008. Poverty and access to healthcare in developing countries. Ann. N. Y. Acad. Sci. 1136 (1), 161–171. Penchansky, R., Thomas, J.W., 1981. The concept of access: definition and relationship to consumer satisfaction. Med. Care 19 (2), 127–140. Starkey, P. Hine, J., 2014. Poverty and sustainable transport; How transport affect poor people with policy implications for poverty reduction. Retrieved August 12, from 〈https://sustainabledevelopment.un.org〉. Wa West District Assembly (WWDA), 2014. Medium Term Development Plan: 2014-2017. Wa, Ghana. World Health Organization, 2011. WHO statement on antenatal care. Geneva.
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