Physical access to primary health care in Andean Bolivia
Introduction
Primary health care has been officially recognized as the universal solution for improving world health since the Alma Ata Conference in 1978 (WHO/UNICEF, 1978). However, limited physical access to primary health care continues to be a major impediment to achieving the goal of health for all. Nowhere is this more starkly apparent than in the Bolivian Andes, where rugged topography, variable climates and isolated populations — combined with scarce and poorly distributed health care resources and socioeconomic barriers — present health care planners with a unique challenge. This paper addresses the problem of physical accessibility in Andean Bolivia.
Studies that deal with such extreme barriers to access as the Bolivian situation presents are relatively rare. Although physical access to health care has been one of the primary concerns of medical geography (Shannon and Dever, 1974, Joseph and Phillips, 1984, Ricketts et al., 1994, Parker and Campbell, 1998), not surprisingly, the bulk of this work has been carried out in industrialized countries and in places where populations are fairly dense. However, some attention has been paid to physical accessibility in developing countries (e.g. Annis, 1981, Stock, 1983, Gesler et al., 1987) and in rural areas where populations may be isolated (e.g. Basu, 1982, Joseph and Bantock, 1982, Rushton, 1984). This study contributes to this latter literature.
The basic procedure for measuring physical accessibility involves the calculation of some measure of distance (map, road, time, perceived) between consumers of care and health care resources such as hospitals, clinics and various types of health personnel. In the past, distances were often determined rather imprecisely and did not take such variables as topography into account. More recently, however, the availability of global positioning system (GPS) units and geographic information systems (GIS) software has greatly enhanced the accuracy and flexibility of distance measures, the ability to present visual displays of accessibility research and the capability to model many different scenarios rapidly (Albert et al., 1995). In countries such as the US, measuring physical accessibility is greatly facilitated because data files containing very detailed road networks and digital elevation models (DEMs) are available. Even with the availability of GPS and GIS, however, this task is often quite formidable in developing countries. Another unique contribution of this paper is the use of these techniques in the Bolivian Andes.
The following section briefly expands on the ideas introduced here. Then we provide some context for the study by summarizing health care resource availability and distribution in Bolivia. In the next section we focus our attention on three study sites, using maps and satellite imagery to show that they represent three very different geographies. Then we briefly describe the methods used to measure physical accessibility. Finally, we display and discuss physical access to health care resources in the three sites, both given the current situation and an alternative scenario where recommended changes have been made in the numbers and distributions of health personnel.
Section snippets
Background
A central problem in establishing health care systems is to provide resources in locations that are close enough to be reached with a reasonable amount of effort by populations being served. Therefore, ensuring physical accessibility or the potential for provider/consumer links to be formed is a key concern. Physical distance between provider and consumer has been recognized as an important barrier to care for several decades (e.g. see King, 1966) and studies have shown that most people will
Health care resources and distribution
The Andean environment, historical and cultural realities, health personnel imbalances and curative (as opposed to preventive) health policies have hindered the development of rural primary health care programs, contributing to the poor access to primary health care in rural areas. The rugged topography and harsh climate — when combined with the limited infrastructure as a result of centuries of disinterest and neglect of the rural indigenous population — has made social development
Study sites
The sites selected for this study are located in the department of La Paz, just to the northeast of Lake Titicaca (Fig. 1). The physical geography of this area truly is spectacular. The eastern cordilleras (ranges) of the Andes dominate the landscape in the west, while eastern areas are largely uninhabited montane rainforest environments. The classic representation of agro-ecological altitudinal belts also can be found in the study sites, with elevations ranging from 200 to just under 6000 m.
Methodology
Since much of the study area is not covered by maps of sufficient detail, it was necessary for the primary author to travel to Bolivia in the summer of 1997 to georeference communities and gather ground control points (GCPs) for a digital Landsat Multispectral Scanner (MSS) Image to aid in the development of a GIS for the three study sites. This field research was in conjunction with the Bolivian NGO (non-governmental organization) CSRA (Consejo de Salud Rural Andino) and is of vital interest
Carabuco health area
Within the Carabuco health area exist 34 communities which are grouped into six health sectors based on physical accessibility and population densities. CSRA is the institution responsible for the administration of the health programs in the Carabuco health area. Program activities are overwhelmingly preventive in nature, although limited curative services are provided at the health sectors and in the Carabuco Hospital. A total of nine health personnel practice within the Carabuco health area.
Summary and conclusions
Existing distributions of health personnel and access to primary health care services are clearly inadequate for the majority of the population in the study sites, with the exception of the Carabuco health area. Severe imbalances exist in the type, number and spatial distribution of health personnel, leading in turn to limited physical accessibility. The majority of the population in Ambaná and Charazani health areas has limited access to primary health care, defined by travel times on foot of
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