ArticleBMJ global health2021
Geographic barriers to establishing a successful hospital referral system in rural Madagascar.
Article in BMJ global health, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 12 papers.
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Who cites it
12 citing papers in PubMed.
- Geospatial analysis of COVID-19 vaccine access in Kenya: the interplay of travel time, perceived availability, and vaccine uptake.Journal of global health · 2026Article
- Pathogenesis, Diagnostic Advances, and Therapeutic Management of Chronic Obstructive Pulmonary Disease: A Narrative Review.International journal of chronic obstructive pulmonary disease · 2026Review
- Evaluation of a diabetes decentralization program in rural Madagascar using the RE-AIM framework.PLOS global public health · 2026Article
- Optimizing people's movement across the health system: a scoping review of referral systems within a primary health care approach.Primary health care research & development · 2025Article
- Article
- Changes in child mortality and population health following 10 years of health systems strengthening in rural Madagascar: A longitudinal cohort study.PLoS medicine · 2025Article
- Public health surveillance of tropical diseases in Madagascar: a scoping review of population burden, intervention strategies, and health system responses.BMC public health · 2025Article
- Referral experiences of healthcare consumers: results from a cross-sectional study in urban slums in southeast Nigeria.Frontiers in public health · 2025Article
- Designing and Evaluating a Health System Resilient to Extreme Weather Events in Rural Madagascar.Annals of global health · 2025Article
- Population health and sociodemographic variables as predictors of access to cardiac medicine and surgery in Haiti.Global health research and policy · 2023Article
- Identification of factors associated with residual malaria transmission using school-based serological surveys in settings pursuing elimination.Malaria journal · 2022Article
- Geographic barriers to care persist at the community healthcare level: Evidence from rural Madagascar.PLOS global public health · 2022Article
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Authors and funding
19 authors.
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Abstract
backgroundThe provision of emergency and hospital care has become an integral part of the global vision for universal health coverage. To strengthen secondary care systems, we need to accurately understand the time necessary for populations to reach a hospital. The goal of this study was to develop methods that accurately estimate referral and prehospital time for rural districts in low and middle-income countries. We used these estimates to assess how local geography can limit the impact of a strengthened referral programme in a rural district of Madagascar.
methodsWe developed a database containing: travel speed by foot and motorised vehicles in Ifanadiana district; a full mapping of all roads, footpaths and households; and remotely sensed data on terrain, land cover and climatic characteristics. We used this information to calibrate estimates of referral and prehospital time based on the shortest route algorithms and statistical models of local travel speed. We predict the impact on referral numbers of strategies aimed at reducing referral time for underserved populations via generalised linear mixed models.
resultsAbout 10% of the population lived less than 2 hours from the hospital, and more than half lived over 4 hours away, with variable access depending on climatic conditions. Only the four health centres located near the paved road had referral times to the hospital within 1 hour. Referral time remained the main barrier limiting the number of referrals despite health system strengthening efforts. The addition of two new referral centres is estimated to triple the population living within 2 hours from a centre with better emergency care capacity and nearly double the number of expected referrals.
conclusionThis study demonstrates how adapting geographic accessibility modelling methods to local scales can occur through improving the precision of travel time estimates and pairing them with data on health facility use.
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