Geographic access is defined as the absence of barriers including distance, transportation, and other physical challenges in accessing care when needed. This is influenced in part by decisions made in allocation of resources, equity, and investments into infrastructure.
As with any barriers to care, stakeholders must first ask who is not accessing care due to geographic barriers and why in order to develop implementation strategies that address contextual realities.
It is important to note that geographic barriers are best measured and discussed by the amount of time it takes to travel to services rather than physical distance; travel time can account for terrain and transportation availability. Most often, individuals who live in hard to reach areas, rural areas, or conflict zones face the greatest barriers in geographic access to care. However, it is also possible that access reforms target these groups specifically, leaving gaps elsewhere. Access barriers may also align with social characteristics. If there are restrictions on the movement of groups of people, – for instance, if women are unable to travel without accompaniment – geography may disproportionately disfavor these groups.
Worldwide, there is a substantial shortage of health workers to provide comprehensive primary care services to all populations.8 An adequately sized and competent health workforce is a precondition for ensuring geographic access to health services. Providers must exist and be appropriately distributed both in quantity and cadre. Strategies for strengthening the health workforce will be discussed in more detail in the Workforce Improvement Strategies module. However, there are certain workforce considerations that are particularly salient to geographic access. There are three ways that a country may be experiencing a shortage of providers that would contribute to geographic inaccessibility:
All of these workforce concerns may impact patients’ experiences with geographic access to care, and adequate attention to distribution of the health workforce can increase patients’ trust in the health system and its governing structures.9
Geographic access is also characterized by the physical availability and distribution of clinics. While certain health activities can be provided in community centers or homes, others require supplies, equipment, and/or technology that must be housed within a physical clinic. In areas with very low population densities, it may be logical to rely more heavily on community-based health services with systems for ready access to emergency care and referral systems for ensuring access to higher levels of care when needed. Mobile clinics are also often used to meet gaps in the availability of facilities. However, it is important to note that by nature of being mobile, these clinics will not contribute to the formation of continuous relationships between patients and providers.
Geographic accessibility may also be constrained by inadequate transportation. Even in areas where clinics are close to communities, if there is not adequate transportation to reach them, accessibility is compromised. The same barriers experienced by patients may also apply to providers and influence their ability to access facilities to provide care. For instance, in Iraq, one study found that doctors faced many transportation barriers including checkpoints, curfews, and inadequate transportation, resulting in widespread absenteeism.10 Similar to areas with inadequate facility distribution, transportation barriers can be mitigated through implementation of community-based services - often delivered by CHWs – for non-acute care. Community-based care is discussed briefly in “service delivery activities” below and in greater detail in the Proactive Population Outreach module.
Strategies to effectively and equitably retain, recruit, and station providers – commonly called Posting and Transfer (P&T) - include: expanding medical education and in-service training targeted at specific cadres or regions; strengthening primary and rural care programs in existing institutions; providing incentives and support for providers to work in rural areas, public facilities, or primary care settings; instituting mandatory civil service in these same areas; training facility-based providers from underserved areas who are more likely to return or remain in these areas; and developing methods for improving provider motivation and satisfaction such as supportive supervision, career development, adequate workload and facility infrastructure, and continuing education, so as to promote provider retention.1112 1314 More information on provider motivation is included in the provider motivation module.
Despite P&T being an important consideration for operations of a health system, delegation of roles and responsibilities and methods for provider deployment is vastly understudied in the LMIC literature. Formal responsibility for P&T is often included in policies in public administration structures or various levels of the Ministry of Health within a given country. However, there are often informal norms or practices that also govern the placement and distribution of providers such as preferential treatment for specific cadres, bribery, nepotism, or gendered delegation of responsibilities.9 When instituting systems and policies for P&T, it is important that stakeholders explore some of these informal practices that influence provider distribution through qualitative or participatory evaluation and research to inform policies and interventions.
It is also important for stakeholders to consider incentives or specific training that can help providers more successfully carry out their responsibilities in underserved areas. For instance, if countries are struggling with posting and/or retention in rural areas, they could increase salaries or institute loan repayment for providers who serve in these areas. Non-financial support that is important to consider may include cultural or language training and systems for providing in-service training and professional growth.15
Community health workers (CHWs) can be a valuable resource for increasing geographic access to health services. CHWs require less training than doctors or nurses and thus can be deployed quickly and are quite cost effective. Additionally, they have been shown to effectively provide high quality preventative and some curative care in remote areas where access to facilities is challenging (see proactive population outreach within "service delivery acticites" and in the Population Health Management module). While CHW-based care is not a substitute for comprehensive primary care, and CHWs should have a clear and limited set of responsibilities, CHWs can play an important role in the health system. In addition to improving health outcomes, bolstering the CHW workforce can have an intersectoral impact, creating job opportunities and ultimately reducing unemployment and strengthening economies. While CHWs may be cost-effective in terms of salary and training, it is important to note that they often require additional resources such as transportation or communication technology in order to be effective, and these inputs should be considered during program planning and budgeting.
A successful CHW program must include a comprehensive plan considered from a whole health system perspective. UNAIDS has developed a report calling for increased CHW training and deployment across Africa. Within the report, they highlight key barriers that may arise when scaling-up CHW programs. These include inadequate political commitment, insufficient funding, policy and regulatory gaps, and lack of partnership with other health professionals.8 Although they are framed as challenges, they can also be considered opportunities for collaboration during initial planning and implementation.
In addition to many individual countries’ programs, there are several large CHW-initiatives such as the African Union’s 2 million CHW Initiative, which has committed to bolstering the health workforce throughout African settings by training two million new CHWs.8 The new CHW Academy will also focus on training and development of global best practice standards for CHWs. Additional information on the potential of CHW programs – including a report synthesizing implementation considerations from six high-performing CHW programs - can be found at CHW Impact.
In addition to improving geographic access to services through community-based care, health system stakeholders may also choose to engage in partnerships to provide greater access to and quality of primary health care services. In certain areas, public/private partnerships (PPPs) may increase geographic accessibility if private organizations already have adequate physical infrastructure and are set up in such a way to promote partnership.16 PPPs are sometimes pursued solely for the building of infrastructure; these partnerships often result in faster and more efficient development of facilities. However, PPPs are also pursued in instances where public entities work with private ones to use existing physical facilities and/or service delivery structures. This more comprehensive PPP model is often called an “integrated partnership”.17 In an integrated partnership, governments will contract private organizations for use of existing infrastructure and service delivery in places that lack access to public facilities. This requires a shift in the role of the government from providers of care to managers, regulators, and purchasers. Additionally, these partnerships must entail a formal agreement between the private organization and the government with defined projects and payment contingent upon fulfillment. Thus, there must be effective performance measurement and management systems in place to ensure that goals are achieved. These partnerships should also not increase costs at the point of care, and under the best circumstances, they should improve quality while reducing out of pocket payments.
It is important to note that one method for addressing inadequate facility distribution – particularly in conflict zones where facilities have been destroyed or are inaccessible – is mobile clinics. While there are certainly benefits associated with mobile clinics such as quick access and flexible infrastructure, mobile clinics are not a solution for strengthening a primary care system in the long term. By nature of mobility, patients are unable to form continuous relationships with providers and clinics are not accessible at all times, compromising first contact accessibility.
With appropriate human resources and facility infrastructure, stakeholders can optimize geographic access by considering the types of services they provide and how they work with local populations. There are three activities in particular that can have a distinct impact on geographic access: empanelment, proactive population outreach, and e-health. A brief overview of each is described below though more information is included in their respective Improvement Strategies modules.
Empanelment is the active and ongoing assignment of an individual or family to a primary care provider (doctor, nurse, or other clinical provider) and/or care team for the provision of primary health care. It is the organizational foundation for population health management.18 Empanelment establishes a point of care for individuals and simultaneously holds providers and care teams accountable for actively managing care for an enumerated panel of individuals. There are three methods for establishing panels: geographic, voluntary, and insurance-based.18 Establishing panels based on pre-established geographic or municipal boundaries may help stakeholders understand where and why certain groups are experiencing geographic barriers to care and begin the process of developing infrastructure to remedy these gaps. Thus, while empanelment itself will not relieve geographic barriers, the structure may be a useful starting point for establishing community-based care and ensuring that all community members are under the purview of a provider. Find more information in the empanelment module.
Certain health activities can be effectively delivered directly in communities, decreasing geographic barriers to care. Some of these services include: diagnosis, referral, and treatment of certain illnesses; health education; identification of at-risk individuals or families; counseling and/or provision of family planning; and immunization.19 While these services are not fully comprehensive, they cover basic health needs that may be neglected if individuals are unable to easily access a facility, and preventive and promotive care may effectively decrease the need for some curative care services. Additionally, many of these services can be provided by community health workers (CHW) who can be trained for targeted service provision, in a cost- and time-efficient manner. Community-based care is an effective strategy for increasing access, particularly in areas with low population densities where it is not cost-effective to build and staff facilities. Proactive population outreach may also improve timeliness (C3.c) and provider workload in facilities; patients no longer have to visit facilities for certain health services, freeing appointment time for services that must be provided in facilities. Find more information in the proactive population outreach module.
Electronic health or mobile health (collectively described as e-health here) can facilitate access to care in areas where clinics are inaccessible but sufficient technological infrastructure is in place. A review of e-health in LMIC by the Center for Health Market Innovations found that 42% of programs using information communication aim to extend geographic access to health.20 Using computers and phones, patients and providers may access telemedicine videoconferencing or receive consultations via helplines or text messaging. These services are not exclusive to primary care and can also be used to strengthen access to specialty care (see ECHO below). The following costs must be considered for budgeting at the outset of health programs as embedded costs in any program as well as continuing costs after implementation:
An important consideration is the sustainability of these programs; 47% of the programs identified in the Center for Health Market Innovations review were donor-funded.20 Additionally, often free platforms do not generate sufficient profits to sustain the programs, making them less reliable. As with any intervention dependent upon technology, implementers must consider learning curves and technological literacy, language barriers for any automated systems, and access to infrastructure for this technology.21 Finally, when implementing electronic health interventions, it is important to consider if there are regulatory frameworks in place to govern how clinical care is provided. Find more information in the information systems use module.
Transportation can pose a barrier to first contact access if patients do not have access to vehicles or if available vehicles are too costly or not appropriate for the terrain. Additionally, transportation barriers may occur when primary care facility refer patients to higher level facilities. Most interventions intended to ease transportation barriers focus on antenatal care and delivery in an effort to increase facility-based births and promote practices that can prevent maternal and neonatal mortality.22
As discussed in financial access, transportation vouchers may be a solution when cost is the primary barrier. In situations where there are no available transportation vendors regardless of cost, a multi-faceted intervention may be required. Facilities can work with community members to procure and stock vehicles (these may range from ambulances to motorcycles or carts). However, these transportation systems must be coupled with adequate means of communication so patients can access vehicles and drivers when needed.
It is important to reiterate that transportation to care is only one potential barrier to receiving the right care at the right place at the right time. Aligning with the WHO’s three components of emergency care, patients often face delays in seeking care, reaching care, and receiving care once at a facility.23 Transportation interventions can only address the second delay and must be coupled with appropriate education on when and how patients can seek care as well as high quality services at the point of care.22 Some examples of transportation interventions are discussed in “What others have done”.
PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.
Beginning in 2013, Brazil addressed geographic disparities in access to health services through a multi-faceted workforce program called Mais Medicos (More Doctors). Prior to Mais Medicos, the distribution of physicians ranged from 0.71 to 3.09 physicians per 1000 people throughout the country, with significant disparities between states.24 Brazil had historically experienced challenges retaining doctors due to poor infrastructure and job security as well as the absence of clear career development pathways.
The first component of Mais Medicos involved increased recruitment of primary care physicians, many from Cuba. Physicians were provided incentives, lodging, and three-year work contracts, and all municipalities were invited to take part although priority was given to regions with extreme poverty, those that were historically deprived, or areas with indigenous populations.24 Within two years, the government of Brazil had recruited more than 18,000 physicians, mostly through a collaboration with the Pan-American Health Organization and the Government of Cuba.25 To further expand access, Brazil coupled these efforts with two other reforms. The first focused on increased infrastructure. Municipalities were invited to apply for funds to improve facilities or secure necessary equipment. The second – and long-term - strategy within the Mais Medicos program was the development of medical school programs in rural regions or regions with few doctors. Priority for this program was given to areas more than 75km from a medical school. Through these three components of Mais Medicos, Brazil doubled the number of municipalities with greater than 1 doctor for every 1000 individuals between 2013 and 2015 and increased coverage of PHC services from 77.9% to 86.3% in the same time period.24 While the strategy of recruiting foreign physicians successfully improved geographic access to care in this context, it remains to be seen whether this strategy is sustainable over time.
After the collapse of the Taliban in 2001, Afghanistan’s health system was in a state of crisis. The maternal mortality ratio was 1600 deaths per 100,000 live births, the highest ever recorded, and less than 10% of the population lived within a one hour walking distance to a health facility.16 In conjunction with other stakeholders, the Ministry of Public Health drafted a Basic Package of Health Services (BPHS) to strengthen the health system. The services incorporated in the BPHS included maternal and newborn health, child care and immunization, public nutrition, communicable diseases, mental health, disability, and regular supply of essential drugs. However, the MOPH lacked the facility infrastructure necessary to provide these services, and its capacity was insufficient to deliver the breadth and dose of care needed to improve access and outcomes. To remedy this gap, the MOPH partnered with NGOs to provide the BPHS. NGOs were chosen through a bidding process after which the selected organizations received 1-3 year contracts with payment contingent upon meeting pre-specified goals. In addition to these partnerships, the MOPH instituted community-based care delivered by CHWs at rural health posts. These efforts resulted in enhanced access and utilization, with a marked increase in annual patient visits from 2.0 million to 44.8 million.16
In 2008 the government of Lesotho, recognizing the need to rebuild the only tertiary hospital in the country, entered a public-private integrated partnership with the goal of improving quality of care without compromising patient cost.17 Through a competitive bidding process, the government selected the organization Tsepong to design and build a hospital and gateway clinic, update filter clinics, and provide all services for an 18-year contract. Central to the commitment was improving quality and access, specifically to accomplish the goals of a 24% increase in outpatient visits and a 21% increase in inpatient visits. Tsepong comprises community groups, funders, and providers and as such has been committed to social accountability.26 Local businesses, women’s groups, and physicians comprise 40% of Tsepong, ensuring that service delivery is accountable to patient needs and that adequate working conditions and career development are in place. Additionally, the Government of Lesotho has worked to ensure that services are high-quality through quarterly audits conducted by an independent management company and required accreditation of all providers. The hospital has been serving patients since 2011.
Various telemedicine projects have demonstrated potential in increasing geographic access to higher levels of care without substantial investments in workforce or infrastructure. Project ECHO is a telemedicine initiative that was launched in the United States in 2003 and now operates in 23 countries.27 Project ECHO supports primary care providers in the treatment and management of complex conditions and is particularly beneficial in areas with limited access to specialized or tertiary care.28 The services provided through Project ECHO differ according to the burden of disease, need, and access in each location. For instance, in Namibia, Project ECHO was instituted in 2014 to improve HIV care and currently facilitates 30 weekly HIV clinics for providers at ten sites across the country. While this technology has the potential to improve access to care, the success of this initiative depends upon adequate facility infrastructure to support telecommunication, availability of primary care providers to administer care as directed, availability of specialized providers to direct care via telecommunication, and availability of drugs and equipment for treatment. A similar use of telemedicine is utilized in Alaska where the Southcentral Foundation’s Nuka System of Care regularly sends care teams to rural areas. During these consultations, primary care providers can use telecommunication to discuss complex care treatment with specialists stationed in larger cities, as needed.29 This use of telemedicine for access to specialized care promotes continuity and coordination with a primary care provider as they are needed to connect patients with specialists and administer care.
Telehealth can also be used to support direct communication between providers and patients in homes or facilities. In Ghana, a joint provider and patient mobile health program was designed to improve the recording of antenatal and postnatal patient data while also making patients aware of appointments or pregnancy-related consideration.30 The demand-side program, called Mobile Midwife, delivered voice recorded messages to patients according to their gestational age or the age of their infant. Voice recording helped overcome limitations related to low literacy, and messages were recorded in the local language and attuned to specific local values or beliefs. As with many mobile health interventions, availability of mobile phones and connectivity were limitations in effective use of this technology.
Mobile clinics are often used to provide primary care in crises where access to services has been severed due to widespread infrastructural damage, safety concerns, or inadequate capacity to address specific higher-level care services such as HIV. Recently, the WHO has implemented clinics in Iraq, Jordan, Syria, Ukraine, and Yemen. In each setting, the supply of vans and equipment, as well as partnerships with local providers, differs according to existing infrastructure.31 However, mobile clinics have also been implemented in non-acute settings to provide continuous access to care in places where geographic access poses a barrier to PHC. In Kazakhstan, the Ministry of Health partnered with the Committee of Emergency Situations within the Ministry of Internal Affairs to develop three train-based clinics. Each train comprises eight wagons with clinical, diagnostic, and radiology equipment. Thirty-six medical staff including 18 specialists work in conjunction with 44 operations personnel to provide care in 832 stations on a rotation of approximately 20 days.32 Between 2010 and 2014, the trains have provided care to nearly 37,000 individuals who would otherwise have limited access to primary health care. This intervention demonstrates creative use of existing infrastructure to deliver care to remote populations. While mobile clinics are commonly implemented in crises, and – as in the Kazakhstan case study – may be capable of providing pre-scheduled and non-urgent care, a mobile and thus intermittent system is unable to provide first-contact, continuous, and comprehensive care and may not be a reasonable option for sustainable PHC system strengthening.
The Ghana Health Service launched the Sustainable Emergency Referral Care (SERC) program in the Bongo District in 2012, and it was subsequently extended to a 12 district pilot in 2013.22 The primary purpose of SERC was to enable a community and sub-district level emergency transport system which was supported by communication technology and community education. SERC was planned and implemented with substantial community input. The expanded pilot was supported by a fleet of 24 three-wheel motorcycles that were appropriately modified to include necessary medical and maintenance equipment. These motorcycles – called Motorkings – were distributed among the 12 districts using geographic information systems (GIS) data, and each was supported by two volunteer drivers. Health facilities, volunteer drivers, and community health officers were given mobile phones to ensure that all communities had communication capabilities. While payments were not required for pregnant women and children under five, other patients were charged a small fee determined by the District Health Management Team. Finally, awareness activities were planned during pre-existing community meetings called durbars. SERC was able to direct emergency care patients to facilities that had the capabilities to manage their acute needs, reducing facility-based mortality and accident-related mortality. However, in places where competent facilities were far from communities, patients often neglected to use SERC.22 Thus, emergency transport systems should be coupled with efforts to improve capacity in first contact facilities, and this challenge may be more acute in countries where the quality of care is weaker than Ghana.
PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.
The questions below may be a useful starting place for determining if Geographic Access is an appropriate area of focus for a given context and how one might begin to plan and enact reforms:
For instance, geographic access may be worst among poor populations, rural areas, and/or among certain ethnic or religious groups. This question is a starting point for stakeholders to understand areas of weakness specific to geographic access. Tools and frameworks for assessing access to care can be found on the Access homepage. Note that geographic access may be enhanced through empanelment, discussed in Population Health Management. Through geographic empanelment, patients will be linked with a provider or care team who are responsible for their care.
It is important to understand the composition of the workforce and if certain geographic areas lack any needed cadres, both in number and in specialty. This can help inform targeted strategies to bolster human resources as described in “What it is”.
In certain geographic areas with especially small populations, it may not be efficient to establish a permanent facility staffed with a provider or care team. However, there should be outreach activities and systems in place to ensure that these populations still have access to care. Community Health Workers (CHWs) are commonly deployed to communities to provide community-based care and education. CHW programs can help bolster the health workforce, but they do have a limited scope and must be linked to doctors or more robust care teams through pre-established referral processes. Additionally, public-private partnerships (PPPs) or more robust transportation infrastructure – or better availability to existing transportation through vouchers - may be an efficient way to provide services in areas without public facility infrastructure.
In order to improve geographic access to care in remote or rural areas, stakeholders must be creative and should consider how they can leverage existing resources and systems. This is highly contextual and will differ between and across countries. Assessments of existing systems, infrastructure, and the acceptability of new programs should involve robust community input using both qualitative and quantitative methods.
PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.
In order for interventions aimed at improving Geographic Access to be most successful, the following elements of the PHCPI Conceptual Framework should be in place or pursued simultaneously:
Regardless of financial, geographic, and timely access to services, it is unlikely that patients will access care if they perceive that providers lack competence, services are not tailored to their needs, and care is not delivered with trust and respect. Additionally, if patients do seek care that is not high quality, it is unlikely to result in improved outcomes. Thus, if patients are not accessing services, it is important to understand whether it is due to perceived quality of care or accessibility, and if both are lacking, they may have to be addressed in tandem to improve utilization of care and subsequent positive health outcomes and impact.
Learn more in the Provider Competence & High-Quality Primary Health Care Improvement Strategies modules.
There must be an adequate number of reliable and competent providers to serve a geographic area and provide care both in facilities and communities at convenient and accessible times. As discussed in “What it is”, there are numerous strategies that stakeholders can implement to improve provider supply, including recruitment, enhanced and more widespread education, incentives, improved work conditions, and eHealth strategies.
Learn more in the Workforce Improvement Strategies module.
In order to provide geographically accessible services, adequate physical facilities must be available. In certain areas, it may not be efficient to build a facility to serve a small or widely dispersed population and health systems may rely more heavily on community-based providers. However, even in these cases, community-based providers must have access to a facility – even if it is relatively far from the community - where they can restock necessary drugs and supplies or refer patients when they require higher levels of care. Stakeholders should focus on ensuring that community members have access to the necessary transportation to these higher-level facilities.
Learn more in the Facility Infrastructure Improvement Strategies module.
Empanelment is both an organizational strategy and approach to care that may help alleviate geographic inequities in access to health. Particularly when health systems delineate panels through geographic assignment, as in Costa Rica,33 this can serve as a catalyst to ensure that all populations have geographically accessible primary care. Additionally, in areas where there are no physical facilities but populations are empaneled to a provider or care team, service delivery will necessarily be structured and adapted to provide care to these communities through the deliberate allocation of responsibility to a care team.
Learn more in the Empanelment Improvement Strategies module.
Proactive population outreach may be a strategy to mitigate geographic inaccessibility in certain contexts. Particularly in areas where population density is sparse and physical facilities would not serve a substantial enough population, outreach activities in communities and homes can bridge barriers to care.
Learn more in the Proactive Population Outreach Improvement Strategies module.
Certain approaches to improving access require logistical changes within a facility, such as scheduling outreach activities, adopting new appointment systems, or shifting provider schedules to facilitate greater coverage. For all of these changes to be effectively integrated, facilities must have strong leadership and management to communicate, implement, monitor, and adapt necessary changes with internal and external stakeholders.
Learn more in the Facility Management Capability and Leadership Improvement Strategies module.
As with any changes to a health system, it is important to have a clear system in place to evaluate the efficacy of a given intervention. Performance measurement and management systems with clear targets, measurement activities, and plans for improvement should be designed in conjunction with service delivery changes to monitor changes in access and adapt approaches as needed.
Learn more in the Performance Measurement and Management Improvement Strategies module.
In addition to engaging community members in the identification of barriers to care and potential interventions to improve access, social accountability mechanisms should be in place to ensure that community members are able to monitor and react to health systems interventions and changes.
Learn more in the Social Accountability Improvement Strategies module.
PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.
Brief Overview
Each section includes core principles and relevant background on the topic to help stakeholders understand how this topic relates to other parts of the health system and how to begin improvements.
In-depth exploration
Each section links to various external resources including research papers, toolkits, and implementation guides for readers who would like to learn more.
Diagnostic
Countries that have a Vital Signs Profile can use it to identify gaps in their performance and find improvement strategies that are specifically relevant to their context.
Sharing experience and learning from others
Throughout the model, there are case studies that provide examples of how other countries have implemented reforms and the factors that supported implementation. Additionally, if you think others can learn from improvements in your country, you can submit your experience using the "share your experience" tab.
