Impact of traffic variability on geographic accessibility to 24/7 emergency healthcare for the urban poor: A GIS study in Dhaka, Bangladesh

Autoři: Shakil Ahmed aff001;  Alayne M. Adams aff001;  Rubana Islam aff001;  Shaikh Mehdi Hasan aff001;  Rocco Panciera aff001
Působiště autorů: Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh aff001
Vyšlo v časopise: PLoS ONE 14(9)
Kategorie: Research Article
doi: 10.1371/journal.pone.0222488


Ensuring access to healthcare in emergency health situations is a persistent concern for health system planners. Emergency services, including critical care units for severe burns and coronary events, are amongst those for which travel time is the most crucial, potentially making a difference between life and death. Although it is generally assumed that access to healthcare is not an issue in densely populated urban areas due to short distances, we prove otherwise by applying improved methods of assessing accessibility to emergency services by the urban poor that take traffic variability into account. Combining unique data on emergency health service locations, traffic flow variability and informal settlements boundaries, we generated time-cost based service areas to assess the extent to which emergency health services are reachable by urban slum dwellers when realistic traffic conditions and their variability in time are considered. Variability in traffic congestion is found to have significant impact on the measurement of timely access to, and availability of, healthcare services for slum populations. While under moderate traffic conditions all slums in Dhaka City are within 60-minutes travel time from an emergency service, in congested traffic conditions only 63% of the city’s slum population is within 60-minutes reach of most emergency services, and only 32% are within 60-minutes reach of a Burn Unit. Moreover, under congested traffic conditions only 12% of slums in Dhaka City Corporation comply with Bangladesh’s policy guidelines that call for access to 1 health service per 50,000 population for most emergency service types, and not a single slum achieved this target for Burn Units. Emergency Obstetric Care (EmOC) and First Aid & Casualty services provide the best coverage, with nearly 100% of the slum population having timely access within 60-minutes in any traffic condition. Ignoring variability in traffic conditions results in a 3-fold overestimation of geographic coverage and masks intra-urban inequities in accessibility to emergency care, by overestimating geographic accessibility in peripheral areas and underestimating the same for central city areas. The evidence provided can help policy makers and urban planners improve health service delivery for the urban poor. We recommend that taking traffic conditions be taken into account in future GIS-based analysis and planning for healthcare service accessibility in urban areas.

Klíčová slova:

Medicine and health sciences – Critical care and emergency medicine – Earth sciences – Geography – Human geography – Urban geography – Geographic areas – Urban areas – Geoinformatics – Geographic information systems – Social sciences – Engineering and technology – Civil engineering – Transportation infrastructure – Roads – Transportation – People and places – Geographical locations – Asia – Bangladesh – Research and analysis methods – Research design – Survey research – Census – Computer and information sciences


1. Munoz UH, Kallestal C. Geographical accessibility and spatial coverage modeling of the primary health care network in the Western Province of Rwanda. International journal of health geographics. 2012;11(1):40.

2. Masters S, Bursteina R, Amofahb G, Abaogyec P, Kumara S, Hanlon M. Travel time to maternity care and its effect on utilization in rural Ghana: A multilevel analysis. Social Science & Medicine. 2013;93(147–154).

3. Mwaliko E, Downing R, O’Meara W, Chelagat D, Obala A, Downing T, et al. “Not too far to walk”: the influence of distance on place of delivery in a western Kenya health demographic surveillance system. BMC Health Services Research 2014;14(212).

4. Gabrysch S. The influences of distance on health facility delivery in rural Zambia: London School of Hygiene & Tropical Medicine; 2010.

5. Zegeye K, Gebeyehu A, Melese T. The Role of Geographical Access in the Utilization of Institutional Delivery Service in Rural Jimma Horro District, Southwest Ethiopia. Primary Health Care. 2014;4(1). doi: 10.4172/2167-1079.1000152

6. Schoeps A, Gabrysch S, Niamba L, Sié A, Becher H. The Effect of Distance to Health-Care Facilities on Childhood Mortality in Rural Burkina Faso. American Journal of Epidemiology. 2011;173(5):492–8. doi: 10.1093/aje/kwq386

7. Wang F, Luo W. Assessing spatial and nonspatial factors for healthcare access: Towards an integrated approach to defining health professional shortage areas. Health and Place. 2005;11(2):131–46. doi: 10.1016/j.healthplace.2004.02.003 15629681

8. Ray N, Ebener S. AccessMod 3.0: computing geographic coverage and accessibility to health care services using anisotropic movement of patients. International journal of health geographics. 2008;7. doi: 10.1186/1476-072X-7-7

9. Kobusingye OC, Hyder AA, Bishai D, Joshipura M, Hicks ER, C M. Emergency Medical Services. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al., editors. Disease Control Priorities in Developing Countries 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006.

10. Razzak JA, Kellermann AL. Emergency medical care in developing countries: is it worthwhile? Bulletin of the World Health Organization. 2002;80(11).

11. Muckart DJJ. Trauma—the malignant epidemic. S Afr Med J 1991;79:93–5. 1989097

12. WHO. Background paper for the technical consultation on effective coverage of health systems 27–29 August 2001; Rio de Janeiro, Brazil. Geneva, Switzerland: WHO; 2001.

13. Schonfeld HK, Heston JF, Falk IS. Numbers of physicians required for primary medical care. N Engl J Med. 1972;286.

14. Connor RA, Hillson SD, Krawelski JE. Competition, professional synergism, and the geographic distribution of rural physicians. Med Care. 1995;33.

15. Haynes R, Bentham G, Lovett A, Gale S. Effects of distances to hospital and GP surgery on hospital inpatient episodes, controlling for needs and provision. Social Science and Medicine. 1999;49(3):425–33. doi: 10.1016/s0277-9536(99)00149-5 10414825

16. Gyimah S, Takyi B, Addai I. Challenges to the reproductive health needs of African women: on religion and maternal health utilization in Ghana. Social Science & Medicine. 2006;62(12):2930–44.

17. Schuurman N, Fiedler R, Grzybowski S, Grund D. Defining rational hospital catchments for non-urban areas based on travel-time. International journal of health geographics. 2006;5. doi: 10.1186/1476-072X-5-5

18. Guagliardo MF, Ronzio CR, Cheung I, Chacko E, Joseph JG. Physician accessibility: an urban case study of pediatric providers. Health & place. 2004;10(3):273–83.

19. Radke J, Mu L. Spatial decomposition, modeling and mapping service regions to predict access to social programs. Geographic Information Sciences. 2000;6:105–12.

20. Joseph A, Bantock P. Measuring potential physical accessibility to general practitioners in rural areas: a method and case study. Social Science and Medicine. 1982;16(1):85–90. doi: 10.1016/0277-9536(82)90428-2 7100960

21. Luo W, Wang F. Measures of spatial accessibility to health care in a GIS environment: Synthesis and a case study in the Chicago region. Environment and Planning B: Planning and Design. 2003;30(6):865–84.

22. Ye H, Kim H. Measuring Spatial Health Disparity Using a Network-Based Accessibility Index Method in a GIS Environment: A Case Study of Hillsborough County, Florida. International Journal of Geospatial and Environmental Research. 2014;Vol. 1: No. 1, Article 2.

23. Luo W, Qi Y. An enhanced two-step floating catchment area (E2SFCA) method for measuring spatial accessibility to primary care physicians. Health Place. 2009;15:1100–7. doi: 10.1016/j.healthplace.2009.06.002 19576837

24. Luo W, Whippo T. Variable catchment sizes for the two-step floating catchment area (2SFCA) method. Health Place. 2012;18:789–95. doi: 10.1016/j.healthplace.2012.04.002 22560115

25. Kim Y, Byon Y-J, Yeo H. Enhancing healthcare accessibility measurements using GIS: A case study in Seoul, Korea. PLOS ONE. 2018;13(2):e0193013. doi: 10.1371/journal.pone.0193013 29462194

26. Brabyn L, Skelly C. Modeling population access to New Zealand public hospitals. International journal of health geographics. 2002;1. doi: 10.1186/1476-072X-1-1

27. Christie S, Fone D. Equity of access to tertiary hospitals in Wales: A travel time analysis. Journal of Public Health Medicine. 2003;25(4):344–50. 14747594

28. Vanderschuren M, McKune D. Emergency care facility access in rural areas within the golden hour?: Western Cape case study. International journal of health geographics. 2015;14(1):1–8.

29. Yerramilli S, Fonseca DG. Assessing Geographical Inaccessibility to Health Care: Using GIS Network Based Methods. Public Health Research. 2014;4(5):145–59.

30. Magadi M, Diamond I, Rodrigues R. The determinants of delivery care in Kenya. Society of Biology. 2000; 47(3–4):164–88.

31. Raghupathy S. Education and the use of maternal health care in Thailand. Social Science & Medicine. 1996;43(4):459–71.

32. McGrail MR. Spatial accessibility of primary health care utilising the two step floating catchment area method: an assessment of recent improvements. International journal of health geographics. 2012;11(1):50.

33. Alegana VA, Wright JA, Pentrina U, Noor AM, Snow RW, Atkinson PM. Spatial modelling of healthcare utilisation for treatment of fever in Namibia. International journal of health geographics. 2012;11(1):6.

34. Gething PW, Johnson FA, Frempong-Ainguah F, Nyarko P, Baschieri A, Aboagye P, et al. Geographical access to care at birth in Ghana: a barrier to safe motherhood. BMC Public Health. 2012;12(1):991.

35. Noor AM, Amin AA, Gething PW, Atkinson PM, Hay SI, Snow RW. Modelling distances travelled to government health services in Kenya. Tropical medicine & international health: TM & IH. 2006;11(2):188–96.

36. Okwaraji YB, Cousens S, Berhane Y, Mulholland K, Edmond K. Effect of Geographical Access to Health Facilities on Child Mortality in Rural Ethiopia: A Community Based Cross Sectional Study. PLoS ONE. 2012;7(3):e33564. doi: 10.1371/journal.pone.0033564 22428070

37. Mahmud SS, Hoque M, Bashir G, editors. Deficiencies of Existing Road Network in Dhaka Metropolitan City. Publication in 10th Pacific Regional Science Conference Organization (PRSCO) Summer Institute; 2008.

38. Report Community, Zila Dhaka, Population and Housing Census 2011. Dhaka, Bangladesh: Bangladesh Bureau of Statistics; 2012.

39. Cheng Y, Wang J, Rosenberg MW. Spatial access to residential care resources in Beijing, China. International journal of health geographics. 2012;11:32. doi: 10.1186/1476-072X-11-32 22877360

40. Yang D-H, Goerge R, Mullner R. Comparing GIS-Based Methods of Measuring Spatial Accessibility to Health Services. Journal of Medical Systems. 2006;30(1):23–32. 16548411

41. McGrail M, Humphreys J. The index of rural access: an innovative integrated approach for measuring primary care access. BMC Health Serv Res. 2009;9:124. doi: 10.1186/1472-6963-9-124 19624859

42. McGrail MR, Humphreys JS. Measuring spatial accessibility to primary care in rural areas: improving the effectiveness of the two-step floating catchment area method. Appl Geogr. 2009;29.

43. Dai D. Black residential segregation, disparities in spatial access to health care facilities, and late-stage breast cancer diagnosis in metropolitan Detroit. Health & Place. 2010;16.

44. Schuurman N, Berube M, Crooks VA. Measuring potential spatial access to primary health care physicians using a modified gravity model. Canadian Geographer. 2010;54.

45. Wan N, Zhan FB, Zou B, Chow E. A relative spatial access assessment approach for analyzing potential spatial access to colorectal cancer services in Texas. Applied Geography. 2012;32(2):291–9.

46. Houben R, Van Boeckel T, Mwinuka V, Mzumara P, Branson K, Linard C, et al. Monitoring the impact of decentralised chronic care services on patient travel time in rural Africa—methods and results in Northern Malawi. International journal of health geographics. 2012;11(1):49.

47. Rahman MH, Mosley WH, Ahmed S, Akhter HH. Does Service Accessibility Reduce Socioeconomic Differentials In Maternity Care Seeking? Evidence From Rural Bangladesh. Journal of Biosocial Science. 2008;40(01):19–33.

48. Chowdhury ME, Biswas TK, Rahman M, Pasha K, Hossain MA. Use of a geographic information system to assess accessibility to health facilities providing emergency obstetric and newborn care in Bangladesh. International Journal of Gynecology & Obstetrics. 2017;138(2):164–70.

49. Islam MS, Aktar S. Measuring physical accessibility to health facilities—a case study on Khulna City. World Health Popul. 2011;12(3):33–41. 21677527

50. Apparicio P, Abdelmajid M, Riva M, Shearmur R. Comparing alternative approaches to measuring the geographical accessibility of urban health services: Distance types and aggregation-error issues. International journal of health geographics. 2008;7(1):7.

51. McGuirk MA, Porell FW. Spatial Patterns of Hospital Utilization: The Impact of Distance and Time. Inquiry. 1984;21(1):84–95. 6232220

52. Panciera R, Khan A, Rizvi SJR, Ahmed S, Ahmed T, Islam R, et al. The influence of travel time on emergency obstetric care seeking behavior in the urban poor of Bangladesh: a GIS study. BMC Pregnancy and Childbirth. 2016;16(1):1–13.

53. Jahan NA, Howlader SR, Sultana N, Ishaq F, Sikder MZH, Rahman T. Health Care Seeking Behavior of Slum-Dwellers in Dhaka City. Dhaka, Bangladesh: Institute of Health Economics, University of Dhaka, 2015.

54. Baumgart S, Hackenbroch K, Hossain S, Hossain S. Urban Development and Public Health in Dhaka, Bangladesh. In: Kramer A, Khan MH, Kraas F, editors. Health in Megacities and Urban Areas. Contributions to Statistics. Germany: Physica, Heidelberg; 2011. p. 281–300.

55. Dhaka North City Corporation [cited 2016 18 July]. Available from:

56. Dhaka South City Corporation [cited 2016 18 July]. Available from:

57. Dhaka Population [cited 2018 21 January]. Available from:

58. United Nations DESA, Population Division. World Urbanization Prospects: The 2014 Revision, (ST/ESA/SER.A/366). 2015.

59. Demographia World Urban Areas. 12th Annual Edition [Internet]. [cited 18 December, 2016]. Available from:

60. European Commission Humanitarian Aid Office ADPC, Plan Bangladesh, and Islamic Relief Worldwide Bangladesh. Urban Risk Assessment: A Facilitator's Guidebook. 2010.

61. Streatfield PK, Karar ZA. Population Challenges for Bangladesh in the Coming Decades. Journal of Health, Population, and Nutrition. 2008;26(3):261–72. 18831223

62. Gruebner O, Sachs J, Nockert A, Frings M, Khan MMH, Lakes T, et al. Mapping the Slums of Dhaka from 2006 to 2010. Dataset Papers in Science. 2014;2014:1–7.

63. Preliminary Report on Census of Slum Areas and Floating Population 2014. Dhaka, Bangladesh: Bangladesh Bureau of Statistics (BBS), 2015.

64. World Urbanisation Prospects: The 2007 revision. Executive summary. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat (UNPD), 2009.

65. Islam R, Zakaria R, Hasan M, Saha S, Ahmed R, Ahmed S, et al. Health facility mapping in Rajshahi & Narayanganj city corporations, Bangladesh. Dhaka, Bangladesh: icddr,b, 2016.

66. Mock C, Lormand J-D, Goosen a, Joshipura M, Peden M. Guidelines for essential trauma care. Geneva: World Health Organization, 2004.

67. MOLGRDC. Second Urban Primary Health Care Project. Bid Document: Project Management Unit (PMU), Local Government Division, Government of Bangladesh; 2005.

68. Angeles G, Lance P, Barden-O'Fallon J, Islam N, Mahbub AQM, Nazem NI. The 2005 census and mapping of slums in Bangladesh: design, select results and application. International journal of health geographics. 2009;8(1):32.

69. Mohit MA. Bastee Settlements of Dhaka City, Bangladesh: A Review of Policy Approaches and Challenges Ahead. Procedia—Social and Behavioral Sciences. 2012;36(Supplement C):611–22.

70. Patel AB, Waters NM, Ghali WA. Determining geographic areas and populations with timely access to cardiac catheterization facilities for acute myocardial infarction care in Alberta, Canada. International journal of health geographics. 2007;6:47. doi: 10.1186/1476-072X-6-47 17939870

71. Higgs G. A Literature Review of the Use of GIS-Based Measures of Access to Health Care Services. Health Services and Outcomes Research Methodology. 2004;5(2):119–39.

72. Haynes R, Jones AP, Sauerzapf V, Zhao H. Validation of travel times to hospital estimated by GIS. International journal of health geographics. 2006;5. doi: 10.1186/1476-072X-5-5

73. Banik B, Chowdhury M, Sarkar M. Study of the Traffic congestion in Sylhet City. Journal of the Indian Roads Congress. 2009.

74. Anwar AHMM. A Study on Factors for Travel Time Variability in Dhaka City Corporation Area. Journal of Bangladesh Institute of Planners. 2010;3:53–64.

75. Wei R, Clay Mann N, Dai M, Hsia RY. Injury-based Geographic Access to Trauma Centers. Academic Emergency Medicine. 2019;26(2):192–204. doi: 10.1111/acem.13518 30019802

76. Carr BG, Branas CC, Metlay JP, Sullivan AF, Camargo CA. Access to Emergency Care in the United States. Annals of emergency medicine. 2009;54(2):261–9. doi: 10.1016/j.annemergmed.2008.11.016 19201059

77. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emergency Medicine Journal: EMJ. 2007;24(9):665–8. doi: 10.1136/emj.2007.047654 17711952

78. Ravelli ACJ, Jager KJ, de Groot MH, Erwich J, Rijninks-van Driel GC, Tromp M, et al. Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands. BJOG: An International Journal of Obstetrics & Gynaecology. 2011;118(4):457–65.

79. Una E, Chen S, Waldorf B. Healthcare Access in Indiana 2008 [cited 2015 28 October]. Available from:…/Healthcare-Access-in-Indiana.pdf.

80. Klein MB, Kramer CB, Nelson J, Rivara FP, Gibran NS, Concannon T. Geographic Access to Burn Center Hospitals. JAMA: the journal of the American Medical Association. 2009;302(16):1774–81.

81. Branas CC, MacKenzie EJ, Williams JC, et al. Access to trauma centers in the united states. JAMA. 2005;293(21):2626–33. doi: 10.1001/jama.293.21.2626 15928284

82. Hameed SM, Schuurman N, Razek T, Boone D, Van Heest R, Taulu T, et al. Access to Trauma Systems in Canada. Journal of Trauma and Acute Care Surgery. 2010;69(6):1350–61.

83. Ahmed SM, Hossain MA, RajaChowdhury AM, Bhuiya AU. The health workforce crisis in Bangladesh: shortage, inappropriate skill-mix and inequitable distribution. Human Resources for Health. 2011;9(1):3.

84. Dieleman J, Campbell M, Chapin A, Eldrenkamp E, Fan VY, Haakenstad A, et al. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. The Lancet. 2017;389(10083):1981–2004.

85. Smith CM, Fry H, Anderson C, Maguire H, Hayward AC. Optimising spatial accessibility to inform rationalisation of specialist health services. International journal of health geographics. 2017;16(1):15. doi: 10.1186/s12942-017-0088-6 28431545

86. Ahmed B. Contemporary Issues and Priorities in Addressing the Road Safety Problems of Dhaka Metropolitan Area, Bangladesh. Journal of Bangladesh Institute of Planners. 2013;6:103–18.

87. Colossal loss. The Daily Star. 2018 March 25.

88. George AA, Krishna A, Dias T, Vargheese AS, Divya RS, editors. Golden aid an emergency ambulance system. 2017 International Conference on Networks & Advances in Computational Technologies (NetACT); 2017 20–22 July 2017.

89. Khalid M, Khalid NB. Emergency medical services and road congestion: deadly path to hospitals. Pakistan Journal of Public Health. 2017;7(3):127–8.

90. A Modern Dhaka is Key to Bangladesh’s Upper-Middle Income Country Vision [press release]. The World Bank, July 19 2017.

91. Adams AM, Ahmed S, Hasan SM, Islam R, Islam MR, Mehjabin N, et al. Mapping the Urban Healthcare Landscape in 5 City Corporations, Bangladesh. Dhaka: icddr,b, 2015.

92. Adams AM, Islam R, Ahmed T. Who serves the urban poor? A geospatial and descriptive analysis of health services in slum settlements in Dhaka, Bangladesh. Health policy and planning. 2015;30(suppl 1):i32–i45.

93. Health Bulletin 2016. Mohakhali, Dhaka: MIS, DGHS, Ministry of Health and Family Welfare, Bangladesh

94. Bremer R. Policy Development in Disaster Preparedness and Management: Lessons Learned from the January 2001 Earthquake in Gujarat, India. Prehospital and Disaster Medicine. 2012;18(4):372–84.

95. Islam MZ, Hossain KM. Fire Hazards in Dhaka City: An Exploratory Study on Mitigation Measures. IOSR Journal of Environmental Science, Toxicology and Food Technology. 2018;12(5):46–56.

96. Polo G, Acosta CM, Ferreira F, Dias RA. Location-Allocation and Accessibility Models for Improving the Spatial Planning of Public Health Services. PLOS ONE. 2015;10(3):e0119190. doi: 10.1371/journal.pone.0119190 25775411

97. Tang J-H, Chiu Y-H, Chiang P-H, Su M-D, Chan T-C. A flow-based statistical model integrating spatial and nonspatial dimensions to measure healthcare access. Health & Place. 2017;47:126–38.

98. Kiani B, Bagheri N, Tara A, Hoseini B, Hashtarkhani S, Tara M. Comparing potential spatial access with self-reported travel times and cost analysis to haemodialysis facilities in North-eastern Iran. Geospatial health. 2018;13(2).

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