The accessibility of healthcare facilities and services is crucial for the health and wellness of all people and could be a determining factor of a person’s survivability. In Amartya Sen’s book, Development as Freedom, Sen explains how “a great many people have little access to health care … spend their lives fighting unnecessary morbidity, often succumbing to premature mortality,” (Sen). Sen also explains how freedoms are connected to each other in his description of instrumental freedoms: “These instrumental freedoms directly enhance the capabilities of people, but they also supplement one another, and can furthermore reinforce one another,” (Sen). Accessible healthcare influences and is influenced by other freedoms, extending to beyond just the health of a person.
Accessibility of healthcare is one’s ability to travel to and arrive at a healthcare facility and receive the necessary medical attention and treatment to survive. Health outcomes can be measured through values such as child mortality, maternal mortality, life expectancy, stillbirth rates, and more. What makes accessible healthcare so difficult to achieve? “Human mobility—the spatial range and frequency of individual travel—reflects a range of basic needs, social incentives, and economic constraints and inherently encompasses multiple modalities. Therefore, it remains unclear how measures of mobility, which reflect more than just geographic location and physical infrastructure for travel, correlate with access to healthcare or resulting health outcomes.” (Wesolowski et al). The nature of human mobility is something that is not yet understood. In connection to Sen’s definition of freedom, It is this web of components that complicates the question of attaining accessibility to healthcare to more than just some simple ideas.
Countries across the world experience varying levels of success in providing and also supporting accessible healthcare to citizens. Even within each country, there is potential for a wide range of accessibility. However, in general, low- and middle-income countries are much more likely to have difficulty in attaining adequate levels of accessible healthcare and historically have suffered from a multitude of issues that lead to premature mortality (Wariri). Unfortunately, there have not been enough studies on healthcare in low- and middle-income countries to fully grasp and understand the functioning parts of the issues in healthcare to ultimately determine what solutions are needed to be executed (Okoronkwo et al).
I chose to focus my research on Sub-Saharan Africa. This decision was made because of the multitude of low- and middle-income countries that comprise the land and that have historically struggled with quality healthcare (Ariyo & Jiang). The issue of accessible healthcare is rampant in Africa, with large populations with a great number of health conditions and issues attempting to seek help and treatment from a very small number of doctors, healthcare professionals, and healthcare facilities (Ajala & Onyima). Coupled with the obstacles of accessible healthcare is an inability to accurately understand the full situation of Africa due to the fact that there has been a limited amount of research that has been conducted (Dotse-Gborgbortsi et al). Additionally, much of the data that governments, researchers, policy makers, and any other people with influence or interest are observing and using is outdated and insufficiently detailed (Linard et al). I decided to narrow my area of research further, selecting Nigeria as my country of choice. This was done because of the larger population size and influence of Nigeria, which I had hoped would lead me to be able to find a more abundant supply of research.
The most obvious obstacle that most people think of for accessible healthcare is distance. One research study focused on the Ibarapa community in southwestern Nigeria that depended on cattle and thus needed to constantly be on the move for grazing. The researchers used census data and conducted their own surveys of the pastoral nomads in addition to ethnographic fieldwork to gain further understanding. Due to the nature of their society as well as the general location of where they lived, the people had extremely limited access to hospitals that were often only found in urban cities and towns (Ajala & Onyima). Adding on to the difficulties of traveling great distances were conflicts with the locals of these cities and towns that were hostile towards the nomads (Ajala & Onyima). The combination of physical distance and social issues have led the nomads to turn to other options. Namely, drug vendors whose reliability and actual effectiveness at treating health issues are not of high standards. Nomads also have turned to faith-based healing and herbal medicines to either treat wounds or illness or attempt to prevent future illnesses (Ajala & Onyima). Through the inability to find access to healthcare services due to physical distance and animosity from groups of contrasting demographics, the nomads have suffered in their health greatly. The issue of populations living in rural areas with limited access to urban areas is not solely applicable to the pastoral nomads of the Ibarapa community, but can be related to many other groups.
In one research study, population-land cover relationship-based methods were developed and applied to model settlement and population distributions of Africa (Linard et al). The researchers used GlobCover, a global land cover dataset, which when modified was able to provide extremely accurate population distribution data of Africa. Human population census data, as well as official population size estimates and corresponding administrative unit boundaries were used for various African countries. Additionally, the authors used a population density map of Namibia provided by Afripop and a modelling method that differentiates urban and rural populations based on settlements and land cover-based weightings with support from the GRUMP urban extents.Through this process, the researchers were able to create gridded population datasets for each mainland African country. Ultimately, it was concluded that the populations in rural areas would greatly benefit from an improved transportation system to urban cities, which would in turn give them access to an abundance of resources, services, and opportunities (Linard et al). One such benefit would be access to healthcare facilities and services. The methods of this study that resulted in the suggestion that better transportation infrastructure from rural areas to more urbanized areas would improve the ability for populations living in those rural areas to have access to more resources, services, and opportunities can be implemented and applied to many different parts of Africa, one of them being Nigeria.
One of the more interesting methods of data collection was the use of mobile phone data. By combining an analysis of the geographic variation in travel patterns of mobile phone users with travel times to healthcare facilities derived from models, generated through standard cost-distance-based spatial analysis methods, along with surveys, researchers were able to make estimates on the impact of physical access to healthcare on mobility and health outcomes for people (Wesolowski et al). In their results, the researchers found that those with difficult access to healthcare facilities were traveling the most, which reinforced the hypothesis that populations further away from others had more difficulties accessing infrastructure such as healthcare facilities. They also discovered that the findings through mobile phone data suggested more about the economic situations of users as opposed to travel times, emphasizing the notion that accessible healthcare is more deeply integrated with other components than just physical distance (Wesolowski et al).
Data from Nigerian Demographic and Health Survey reports, basic descriptive statistics, test of association, and logistic regression were used to determine the usage of skilled birth attendants and thus explore the reasons why women would be unable to receive assistance from a healthcare facility during pregnancy (Fagbamigbe et al). It was discovered through their surveys and following methods that women of less or no education were more likely to not receive help from a skilled birth attendant during delivery (Fagbamigbe et al). The researchers also discovered through their surveys that women that were more involved with decision making in their household were more likely to have attended a healthcare facility (Fagbamigbe et al). The National Demographic and Health Survey was used by another research team that was attempting to focus on investigating child mortality. They found similar results in terms of the importance of education for the decision to go to a healthcare facility, although this was due to the inability of the parents or guardians to accurately assess symptoms and their indications of life-threatening issues (Ariyo & Jiang). The surveys also indicated that the wealth and economic status of the family could influence them to be less likely to seek treatment and help from healthcare facilities (Ariyo & Jiang). Instead, people with limited financial flexibility are going to try and find cheaper alternatives, that while inexpensive or at least not as costly, will potentially not help the situation and their ailments sufficiently.
One of the more interesting concepts linked with accessible healthcare was the presence and usage of skilled birth attendants. In one particular study a spatial interaction model was utilized, along with emergency obstetric care surveys, gridded estimates of number of pregnancies, and the locations of healthcare facilities (Dotse-Gborgbortsi et al). Instead of using data collected from Demographic and Health Surveys which do not examine attendance at specific facilities nor the effect of quality of services provided, data collected from health management information systems are used. It was found that women were at times going further lengths to go to particular facilities that had better quality of service than other facilities that would have been a closer distance and shorter time (Dotse-Gborgbortsi et al).
One of the more recent world events that has had seemingly unprecedented effects on health news and history has been COVID-19 and the subsequent struggles and failures of governments attempting to salvage economies and businesses. The pandemic started in Wuhan, China in November 2019, and was announced to have reached Nigeria in February 2020. The government has been unable to enforce consistent COVID-19 protocols such as lockdowns and social distancing measures, as well as provide necessary medical equipment for hospitals (Iwuoha et al). A cross-sectional survey and fieldwork visits were conducted to understand impacts of COVID-19 and the following array of policies. As mentioned previously, there are issues with populations living in rural areas with extremely limited access to healthcare facilities. Combine this with the low awareness of remote healthcare services and many people are not able to seek help. The lockdown and distancing policies have caused additional barriers for people with medical issues, aside from the actual concern for COVID-19, and have led people to seek solutions through other means (Iwuoha et al). Many have resorted to self-medication, visiting chemist, pharmaceutical, and medical stores to purchase over the counter drugs (Iwuoha et al). This in turn has caused many health complications. The researchers then argue how the majority that lives in poverty is suffering unjustly due to their limited political influence in policy-making and limited financial resources (Iwuoha et al). It is pointed out that policies are formed with the interests of elites in mind, and in the case of COVID-19, healthcare policies had been made with assumptions that people had easy access to private healthcare service providers, which heavily favored the rich and elite (Iwuoha et al). Through this example of the inadequate COVID-19 policies in Nigeria, Sen’s freedoms and the interconnectedness between them are shown in full. Due to political and economic disparities, those with less are pushed down into further inaccessibility to healthcare services and facilities, leading to vulnerability to health complications, and more concerning, premature mortality.
Several data science methods and datasets have appeared to be significantly influential and commonplace in the research and investigation of accessibility of healthcare in Nigeria. Methods such as interviewing members of a population through surveys or questionnaires and conducting ethnographic fieldwork provide intimate knowledge and help to learn the local complexities and inner workings of issues at hand, rather than interpreting and making assumptions from afar. The use of population distribution sets and census data gathered from national initiatives such as the Nigerian Demographic and Health Survey reports were also utilized fairly often. The issue of accessible healthcare in Nigeria is a perfect example of Sen’s explanation of the many connections and relationships between various freedoms, as factors such as economic flexibility, political influence, level of education, and geographic location co-exist and depend on each other. I think that a more extensive and thorough exploration of the use of models that took in data would be beneficial to further understand the usefulness and implications of the research studies that were discussed. I also think that there was not much research done on the effectiveness of alternatives to healthcare facilities and how significant of a negative impact they had on the health outcomes on populations that were unable to access quality healthcare services and facilities.
Ajala, Aderemi, and Blessing Nonye Onyima. “Public Healthcare Access: Burdens and Adaptation in Ibarapa Nomadic Community of Southwestern Nigeria.” Journal of Asian and African Studies, vol. 56, no. 7, 2020, pp. 1590–1606., https://doi.org/10.1177/0021909620975806.
Ariyo, Tolulope, and Quanbao Jiang. “Mothers’ Healthcare Autonomy, Maternal-Health Utilization and Healthcare for Children under-3 Years: Analysis of the Nigeria DHS Data (2008–2018).” International Journal of Environmental Research and Public Health, vol. 17, no. 6, 2020, p. 1816., https://doi.org/10.3390/ijerph17061816.
Dotse-Gborgbortsi, Winfred, et al. “The Influence of Distance and Quality on Utilisation of Birthing Services at Health Facilities in Eastern Region, Ghana.” BMJ Global Health, vol. 4, no. Suppl 5, 2020, https://doi.org/10.1136/bmjgh-2019-002020.
Fagbamigbe, Adeniyi, et al. “Trends and Drivers of Skilled Birth Attendant Use in Nigeria (1990–2013): Policy Implications for Child and Maternal Health.” International Journal of Women’s Health, Volume 9, 2017, pp. 843–853., https://doi.org/10.2147/ijwh.s137848.
Iwuoha, Victor Chidubem, et al. “Citizens Lack Access to Healthcare Facilities: How Covid‐19 Lockdown and Social Distancing Policies Boost Roadside Chemist Businesses in South‐Eastern Nigeria.” The International Journal of Health Planning and Management, 2021, https://doi.org/10.1002/hpm.3316.
Linard, Catherine, et al. “Population Distribution, Settlement Patterns and Accessibility across Africa in 2010.” PLoS ONE, vol. 7, no. 2, 2012, https://doi.org/10.1371/journal.pone.0031743.
Okoronkwo, Ijeoma L, et al. “The Long Walk to Universal Health Coverage: Patterns of Inequities in the Use of Primary Healthcare Services in Enugu, Southeast Nigeria.” BMC Health Services Research, vol. 14, no. 1, 2014, https://doi.org/10.1186/1472-6963-14-132.
Sen, A. K. (2010). Development as freedom. Oxford University Press
Wariri, Oghenebrume, et al. “The Influence of Travel Time to Health Facilities on Stillbirths: A Geospatial Case-Control Analysis of Facility-Based Data in Gombe, Nigeria.” PLOS ONE, vol. 16, no. 1, 2021, https://doi.org/10.1371/journal.pone.0245297.
Wesolowski, Amy, et al. “Quantifying the Impact of Accessibility on Preventive Healthcare in Sub-Saharan Africa Using Mobile Phone Data.” Epidemiology, vol. 26, no. 2, 2015, pp. 223–228., https://doi.org/10.1097/ede.0000000000000239.