title: Monitoring the impact of decentralised chronic care services on patient travel time in rural Africa--methods and results in Northern Malawi.
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.
  
  
  CONCLUSIONS
  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. However, the model also identified an increasing proportion of ART patients did not attend their nearest clinic.
authors.affiliation: Karonga Prevention Study, Chilumba, Malawi. rein.houben@lshtm.ac.uk
authors.forename: Rein M G J
authors.initials: RM
authors.lastname: Houben
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Van Boeckel
authors.forename: Venance
authors.initials: V
authors.lastname: Mwinuka
authors.forename: Peter
authors.initials: P
authors.lastname: Mzumara
authors.forename: Keith
authors.initials: K
authors.lastname: Branson
authors.forename: Catherine
authors.initials: C
authors.lastname: Linard
authors.forename: Frank
authors.initials: F
authors.lastname: Chimbwandira
authors.forename: Neil
authors.initials: N
authors.lastname: French
authors.forename: Judith R
authors.initials: JR
authors.lastname: Glynn
authors.forename: Amelia C
authors.initials: AC
authors.lastname: Crampin
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D002908:Chronic Disease / Q000628:therapy; D062305:Geographic Mapping; D006297:Health Services Accessibility; D006801:Humans; D008295:Malawi; D011057:Politics; D019035:Rural Health Services; D013997:Time Factors; D014195:Travel
chemical_list: D044966:Anti-Retroviral Agents