Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis

We have assembled the first Pan-African, geocoded database of public hospitals in 48 countries and islands. We estimated that in Africa, about 29% of the population and about 28% of women of child bearing age are geographically marginalised from emergency medical, obstetric, and surgical care, and live more than 2-h travel time to the nearest public hospital; and only 16 of 48 countries have more than 80% of their population living within 2-h travel time of emergency hospital care. We note that smaller countries and islands have proportionately better access to hospital services than in larger countries, where more than 40% of the population live more than 2-h travel time to a public hospital. However, we noted exceptions where large countries have better access quotients than in smaller countries. One important function of routine hospital services is the ability to provide emergency obstetric care, and we have defined access to hospital care for both women of child bearing age and total populations. To reach geographically marginalised populations with hospital care, innovative targeting of emergency care is required, including improvement of transportation modes, ambulatory services, or the numbers of hospitals in specific geographical locations.

Health facility lists in Africa are fragmented, only 31 (31%) of 100 original sources used in this study were from ministries of health, and a diverse list of sources, especially from other governmental and international agencies, were required to provide a more comprehensive understanding of hospital care. The accuracy and completeness of this resource now requires further country and regional level efforts, although our initial database serves as a useful entry point to future hospital censuses in Africa. There was no universal definition of hospital or emergency care, and definitions provided in national health policies varied between countries (appendix pp 4, 5). This absence of a definition has been noted previously and demands a more standard classification of emergency hospital care provision in Africa.21x21English, M, Lanata, C, Ngugi, I, and Smith, PC. Chapter 65: the district hospital. in: DT Jamison, JG Breman, AR Measham,
Disease control priorities in developing countries. 2nd edn. Oxford University Press,
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The role of the private sector in achieving universal health coverage is essential,24x24Morgan, R, Ensor, T, and Waters, H. Performance of private sector health care: implications for universal health coverage. Lancet. 2016;
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Our accessibility analysis had a number of limitations. We were unable to evaluate the efficiency, timeliness, and abilities of referral transport systems in each country with adequate precision at a continental scale. We have not been able to account for frequency of transport services on secondary to main roads connected to hospital locations, the precise transport speeds, how prostrated emergency care patients are transported from households to arterial road networks, or the multitude of other physical and financial barriers to referral from home to hospital in each country or subregions. Additionally, we were unable to account for dynamic population changes at very fine spatial resolutions because these data are unavailable at continental scales. These additional analyses are beyond the scope of the present paper, but should be highlighted to build knowledge across the extensive domains of hospital service access through increased spatial resolution studies25x25Vanderschuren, M and McKune, D. Emergency care facility access in rural areas within the golden hour? Western Cape case study. Int J Health Geogr. 2015;
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and understanding of referral care for hospital services in Africa.

In summary, consensus on the need to integrate emergency care into health systems is increasing.27x27McCord, C, Kruk, ME, Mock, CN et al. Chapter 12: organization of essential services and the role of first-level hospitals. in: HT Debas, P Donkor, A Gawande,
Essential surgery: disease control priorities. 3rd edn. The International Bank for Reconstruction and Development and the World Bank,
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,28x28World Health Assembly. Health systems: emergency-care systems (WHA resolution 60.22). World Health Organization,
Geneva; 2007 ()
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Key towards addressing challenges in emergency care is defining access to hospitals and highlighting populations most distal from these services. We have assembled the first geocoded database of public hospitals in sub-Saharan Africa, and have used this audit or inventory to provide a ranking of the worst and best hospital-served countries that in theory should be able to provide vital emergency services for trauma, surgical, and obstetric patients. Most countries were well below the benchmark set for 2030, where less than 80% of the population lived within 2-h travel time of emergency hospital care. The importance of hospital services goes beyond emergency care, hospitals additionally provide the core backbone to surveillance of emerging or escalating antimicrobial resistance, the detection of new pathogen epidemics, and provide the means to define the operational effectiveness of the introduction of new vaccines or other community-based interventions. Hospitals provide an essential part of pathogen and intervention effect across Africa, and knowing where they are located is essential. Definition of the scope, service provision capacities, laboratory capacities, and optimal catchment populations for emergency hospital care should be a priority. Ultimately, we provide a resource to begin these urgent censuses of hospital services in Africa and where applications extend beyond just defining physical access.

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