Geographic access to care is not a determinant of child mortality in a rural Kenyan setting with high health facility density.
BACKGROUND
Policy-makers evaluating country progress towards the Millennium Development Goals also examine trends in health inequities. Distance to health facilities is a known determinant of health care utilization and may drive inequalities in health outcomes; we aimed to investigate its effects on childhood mortality.


METHODS
The Epidemiological and Demographic Surveillance System in Kilifi District, Kenya, collects data on vital events and migrations in a population of 220,000 people. We used Geographic Information Systems to estimate pedestrian and vehicular travel times to hospitals and vaccine clinics and developed proportional-hazards models to evaluate the effects of travel time on mortality hazard in children less than 5 years of age, accounting for sex, ethnic group, maternal education, migrant status, rainfall and calendar time.


RESULTS
In 2004-6, under-5 and under-1 mortality ratios were 65 and 46 per 1,000 live-births, respectively. Median pedestrian and vehicular travel times to hospital were 193 min (inter-quartile range: 125-267) and 49 min (32-72); analogous values for vaccine clinics were 47 (25-73) and 26 min (13-40). Infant and under-5 mortality varied two-fold across geographic locations, ranging from 34.5 to 61.9 per 1000 child-years and 8.8 to 18.1 per 1000, respectively. However, distance to health facilities was not associated with mortality. Hazard Ratios (HR) were 0.99 (95% CI 0.95-1.04) per hour and 1.01 (95% CI 0.95-1.08) per half-hour of pedestrian and vehicular travel to hospital, respectively, and 1.00 (95% CI 0.99-1.04) and 0.97 (95% CI 0.92-1.05) per quarter-hour of pedestrian and vehicular travel to vaccine clinics in children <5 years of age.


CONCLUSIONS
Significant spatial variations in mortality were observed across the area, but were not correlated with distance to health facilities. We conclude that given the present density of health facilities in Kenya, geographic access to curative services does not influence population-level mortality.
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. jmoisi@jhsph.edu
Jennifer C
JC
Moïsi
Hellen
H
Gatakaa
Abdisalan M
AM
Noor
Thomas N
TN
Williams
Evasius
E
Bauni
Benjamin
B
Tsofa
Orin S
OS
Levine
J Anthony G
JA
Scott
D046688:Child Mortality; D002675:Child, Preschool; D005260:Female; D062306:Geography, Medical; D006297:Health Services Accessibility / Q000191:economics; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D053208:Kaplan-Meier Estimate; D007630:Kenya / Q000453:epidemiology; D008297:Male; D011159:Population Surveillance; D016016:Proportional Hazards Models; D019035:Rural Health Services; D012959:Socioeconomic Factors; D014195:Travel / Q000191:economics* / Q000706:statistics & numerical data