Accessibility to First-Mile Health Services: a Time-Cost Model for Rural Uganda
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Social Science & Medicine 265 (2020) 113410 Contents lists available at ScienceDirect Social Science & Medicine journal homepage: http://www.elsevier.com/locate/socscimed Accessibility to First-Mile health services: A time-cost model for rural Uganda Roberto Moro Visconti a,*, Alberto Larocca b, Michele Marconi c a Department of Business Management, Catholic University of Sacred Heart, Via Ludovico Necchi, 7, 20123, Milan, Italy b Cosmo Ltd., A183/20, 11th Close South Odorkor Estate Greater Accra, Ghana c Universita` Politecnica delle Marche, Dipartimento di Scienze della, Vita e dell’Ambiente, Via Brecce Bianche, 60126, Ancona, Italy ARTICLE INFO ABSTRACT Keywords: This study estimates the geographical disconnection in rural Low-Middle-Income Countries (LMIC) between Barriers to care First-Mile suppliers of healthcare services and end-users. This detachment is due to geographical barriers and to a Remote diagnosis shortage of technical, financial,and human resources that enable peripheral health facilities to perform effective Geographic information systems and prompt diagnosis. End-users typically have easier access to cell-phones than hospitals, so mHealth can help Home-patient to overcome such barriers, transforming inpatients/outpatients into home-patients, decongesting hospitals, Results-based financing Healthcare cost-effectiveness especially during epidemics. This generates savings for patients and the healthcare system. The advantages of mHealth are well known, but there is a literature gap in the description of its economic returns. This study applies a geographical model to a typical LMIC, Uganda, quantifying the time-cost to reach an equipped medical center. Time-cost measures the disconnection between First-Mile hubs and end-users, the potential demand of mHealth by remote end-users, and the consequent savings. The results highlight an average time-cost of 75 min, well above the recommended thresholds, and estimate that mHealth leads to significant savings (1.5 monthly salaries and 21% of public health budget). Community health workers and private actors may re-engineer healthcare resources through Public-Private Partnerships (PPP), remunerated with results-based financing (RBF). These findings can contribute to improving healthcare resource allocation in LMIC. 1. Background governments and donors. A crucial step of the HSC is the complex connection between First-Mile healthcare centers and end-users. The This study adapts existing methods to evaluate mismatches among former are the facilities run by medical doctors that perform primary healthcare products/services suppliers and the needs of the end-users. diagnosis, essential lab tests, and emergency surgery; the latter are all Geographic Information System (GIS) datasets and regional health sec those that should benefit from First-Mile healthcare products. ondary data are used to estimate the average true-time cost of travel to Access to healthcare services is hampered by spatial and temporal well-resourced and competent health facilities and the economic cost of distance between First Mile and end-users. Healthcare centers are often mismatches. The motivations behind this study concern the evaluation accessible via small (unpaved) roads or tracks. (Anderson et al., 2010). of some mHealth technologies and whether the economic benefitof their Worldwide, more than one billion people lack access to healthcare application outweighs mHealth costs. only due to geographical distance (Last Mile Health. Annual, 2018). Healthcare products/services (namely goods, medical services, and Moreover, lack of skilled and trained personnel, equipment, and funding information) are transmitted through the Healthcare Supply Chain hinders an efficient implementation and management of healthcare (HSC) from the earliest supplier to end-users. HSC includes people, access, especially in backward rural areas of Low and Middle-Income processes, policies, technology, and resources aimed to ensure that the Countries (LMICs) (Mills, 2014). right health product reaches the right place in the right conditions and Information exchange between First-Mile and Last-Mile is also time (Gates Foundation (2017) H, 2017). inaccurate, leading to a lack of coordination, management, and audit, An efficientHSC can ensure healthy lives and decrease the incidence with consequent poor governance and accountability of HSC (Yadav, of preventable diseases, safeguarding the financial investments by 2015; Dowling, 2011). This misconnection leads to poor delivery of * Corresponding author. E-mail addresses: [email protected] (R.M. Visconti), [email protected] (A. Larocca), [email protected] (M. Marconi). https://doi.org/10.1016/j.socscimed.2020.113410 Received in revised form 10 July 2020; Accepted 30 September 2020 Available online 5 October 2020 0277-9536/© 2020 Elsevier Ltd. All rights reserved. R.M. Visconti et al. Social Science & Medicine 265 (2020) 113410 primary health products and services in many parts of the world, and of connection between First-Mile hub and end-users in backward areas thus to high mortality rates, especially for children (Nyqvist et al., like Sub-Saharan Africa (Huerta Munoz and Kallesta¨ l,̊ 2012; Allen et al., 2017). 2017). Currently, in many LMICs, the connection between First-Mile and Cost analyses in LMIC usually just focus on costs, not on the end-users is managed by Community Health Workers (CHW), para- geographic elements investigated here, like travel distance to a clinic. professional health workers with basic training, who, as members of the communities, have an in-depth understanding of local social dy 3. Research question namics (Kim et al., 2016; Olaniran et al., 2017). However, CHW pro grams are limited by lack of adequate supervision, continuous Any innovation is helpful if it generates benefits higher than its education, and proper information and logistic support (Kane et al., implementation costs. As reported in the literature quoted above, 2016; Scott et al., 2018). mHealth might create profits, but this economic aspect is not well In sub-Saharan Africa, several hundred million people, who never defined.Are these savings sufficientlyhigher than the costs? Healthcare used traditional landlines, now use mobile phones regularly (Bloomfield costs consist of internal expenditure (what is needed to produce and et al., 2014). This has ignited the African communications revolution, deliver health: equipment, staff, consumables) and external expenditure generating optimism that mobile phones might benefit rural commu (patients’ and families’ time and costs, for example, for travel, accom nities by developing new opportunities and innovation. The use of Short modation, etc.) (Bergmo, 2015). Messaging Service (SMS), wireless data transmission, voice calling, and Following with this background, the paper aims to partially fill the smartphones to transmit health-related information has been offering mentioned literature gap by: the opportunity to overcome the First-Mile and end-users disconnection, improving access to healthcare services (Aranda-Jan et al., 2014; Anstey 1. Quantifying the geographical component of the First Mile end-users et al., 2018). These various technologies, collectively named “mobile disconnection, here described as the time-cost for the population to health” or “mHealth” (Betjeman et al., 2013), have touched the reach an equipped medical center that can accurately diagnose ma boundaries of hard-to-reach areas, positively affecting healthcare in laria or other diseases. Costs include not only transportation (linked African LMICs (Aamir et al., 2018). to the physical distance covered), accommodation and food, but also mHealth softens some HSC bottlenecks as infrastructural de expenses for all family members arising from the disruption of every ficiencies, limited access to medical care, and the shortage of skilled day’s economic and social activities, such as inability to work, healthcare workers (Bloomfield et al., 2014; Hampshire et al., 2015; manage the household, or loss of school days (including also children Opoku et al., 2017; Eze et al., 2018). African LMICs have been too young to be left at home, who should travel with their mothers to embracing mHealth to improve primary healthcare delivery, and the First-Mile healthcare facility). consequently, the scientific literature on mHealth is growing. SMS are 2. Evaluating the time-cost, and thus the savings, produced by the the most exploited mHealth technology, used to communicate to local “mobile point of care” model (Larocca et al., 2016) - an innovative communities the updates on the availability of clinical services (Chic mHealth process to deliver health services. oine and Guzman, 2017) or to overcome poor home management of 3. Indicating how to facilitate better and timely access to healthcare for treatments by patients with chronic disease (Kalyango et al., 2012). backward populations as well as to generate economic and financial Furthermore, mHealth supports the performance of CHW to disseminate savings for the stakeholders that rotate around the HSC: patients, clinical updates and learning materials and to deliver integrated com caregivers (CHW or other), healthcare authorities, etc. munity case management to children sick with diarrhoea, pneumonia, malaria, or HIV (Kallander¨ et al., 2013; Tumusiime et al., 2014; The mHealth “mobile point of care” model (Larocca et al., 2016) is Comulada et al., 2019). Moreover, mHealth is also used to evaluate and designed to tackle