Abstract:
Background: Decentralised health services form a key part of chronic care strategies in resource-limited settings by
reducing the distance between patient and clinic and thereby the time and costs involved in travelling. However,
few tools exist to evaluate the impact of decentralisation on patient travel time or what proportion of patients
attend their nearest clinic. Here we develop methods to monitor changes in travel time, using data from the
antiretroviral therapy (ART) roll-out in a rural district in North Malawi.
Methods: Clinic position was combined with GPS information on the home village of patients accessing ART
services in Karonga District (North Malawi) between July 2005 and July 2009. Potential travel time was estimated as
the travel time for an individual attending their nearest clinic, and estimated actual travel time as the time to the
clinic attended. This allowed us to calculate changes in potential and actual travel time as new clinics opened and
track the proportion and origin of patients not accessing their nearest clinic.
Results: The model showed how the opening of further ART clinics in Karonga District reduced median potential
travel time from 83 to 43 minutes, and median actual travel time fell from 83 to 47 minutes. The proportion of
patients not attending their nearest clinic increased from 6% when two clinics were open, to 12% with four open.
Discussion: Integrating GPS information with patient data shows the impact of decentralisation on travel time and
clinic choice to inform policy and research questions. In our case study, travel time decreased, accompanied by an
increased uptake of services.
