Mapping Physical Access to Health Care for Older Adults in Sub-Saharan Africa and Implications for the COVID-19 Response: a Cross-sectional Analysis

Background: Severe acute respiratory syndrome coronavirus 2, the virus causing COVID-19, is rapidly spreading across sub-Saharan Africa. Hospital-based care for COVID-19 is often needed, particularly among older adults. However, a key barrier to accessing hospital care in sub-Saharan Africa is travel time to the nearest health-care facility. To inform the geographical targeting of additional health-care resources, we aimed to estimate travel time at a 1 km × 1 km resolution to the nearest hospital and to the nearest health-care facility of any type for adults aged 60 years and older in sub-Saharan Africa.

Methods: We assembled a dataset on the geolocation of health-care facilities, separately for hospitals and any type of health-care facility and including both private-sector and public-sector facilities, using data from the OpenStreetMap project and the Kenya Medical Research Institute-Wellcome Trust Programme. Population data at a 1 km × 1 km resolution were obtained from WorldPop. We estimated travel time to the nearest health-care facility for each 1 km × 1 km grid using a cost-distance algorithm.

Findings: 9·6% (95% CI 5·2-16·9) of adults aged 60 years or older across sub-Saharan Africa had an estimated travel time to the nearest hospital of 6 h or longer, varying from 0·0% (0·0-3·7) in Burundi and The Gambia to 40·9% (31·8-50·7) in Sudan. For the nearest health-care facility of any type (whether primary, secondary, or tertiary care), 15·9% (95% CI 10·1-24·4) of adults aged 60 years or older across sub-Saharan Africa had an estimated travel time of 2 h or longer, ranging from 0·4% (0·0-4·4) in Burundi to 59·4% (50·1-69·0) in Sudan. Most countries in sub-Saharan Africa contained populated areas in which adults aged 60 years and older had a travel time to the nearest hospital of 12 h or longer and to the nearest health-care facility of any type of 6 h or longer. The median travel time to the nearest hospital for the fifth of adults aged 60 years or older with the longest travel times was 348 min (IQR 240-576; equal to 5·8 h) for the entire population of sub-Saharan Africa, ranging from 41 min (34-54) in Burundi to 1655 min (1065-2440; equal to 27·6 h) in Gabon.

Interpretation: Our high-resolution maps of estimated travel times to both hospitals and health-care facilities of any type can be used by policy makers and non-governmental organisations to help target additional health-care resources, such as makeshift hospitals or transport programmes to existing health-care facilities, to older adults with the least physical access to care. In addition, this analysis shows the locations of population groups most likely to under-report COVID-19 symptoms because of low physical access to health-care facilities. Beyond the COVID-19 response, this study can inform the efforts of countries to improve physical access to care for conditions that are common among older adults in the region, such as chronic non-communicable diseases.

Funding: Bill & Melinda Gates Foundation.