Geographic Information Systems (GIS) at FHI

Caleb Parker GIS Analyst Behavioral and Social Sciences FHI/NC 919.544.7040 x 11487 cparker2@fhi.org

Contents
Geographic Information Systems Defined FHIs utilization of GIS (FHI/NC): Examples Other examples in Public Health Technical Assistance

GIS in Brief
A geographic information system is a complex tool to create maps of your data, to understand spatial trends and patterns in the data. A GIS has a multitude of functionality, such as:
Displaying data spatially (on a map) Calculating distance, area, and direction Building spatial models to understand how changing one variable can change the map Identifying statistically significant clusters of like values Visualizing topography: elevation, hydrology, land use

ArcGIS is the main software package used, and is produced by ESRI

FHIs Utilization of GIS: Examples

1.
2.

Basic Presentation of Data

o o o Health Facility Locations in Nyanza Province, Kenya Defining Facility Catchment Areas in Rural Ethiopia Identifying Best Locations for Rolling Out PrEP in Bondo, Kenya Calculating Average Distance in Hours by Population Ideas for FHI/Haiti Inter-Facility Referral to Avert Maternal Death and Disability, Ethiopia Mapping High Risk Behavior for HIV Clinical Trial
Note: Text in blue offers explanations of the maps.

Health Facility Coverage Measures

3. 4. 5. 6.

Modeling Walking Travel Time to Nearest Facility

o o o o

Monitoring and Evaluation Facility Referral for Emergency Care Prioritizing Recruitment for Clinical Trials

1. Basic Presentation of Data

GIS is commonly used to simply display data on a map. These maps provide starting questions for research or programs
Where are all the hospitals? Are family planning services offered throughout the district? Where are condoms being distributed relative to the target population?

The following slide shows:

1. Where healthcare facilities in Nyanza Province are located by type

Locations of Key Health Facilities in Nyanza Province, Kenya

This map shows where healthcare facilities are located in the province. The researcher simply needed to know where different types of facilities were located.

2. Health Facility Coverage Measures

Defining a health facilitys coverage area or catchment area is complex. GIS can allow researchers to model and refine the coverage area of a given facility, either by having patient data from health facilities or not. Knowing a coverage area can be used to:
Calculate population served by a health facility Identify places outside of health services Understand spatial relationships between clients and facilities, such as how far a client has to walk or drive to reach care.

The next slides explore examples, including:

o o Defining Facility Catchment Areas in Rural Ethiopia Identifying Best Locations for Rolling Out PrEP in Bondo, Kenya

We need to define catchment areas for the facilities in the green area, so that we can calculate populations that come to each facility. We used data on elevation, roads and streams to figure out where natural breaks between catchment areas might be.

This is the final map of catchment areas. Each catchment area is shaded light to dark green to describe the density of population. Notice how the catchment area boundaries curve and weave, forming random shapes. These shapes are formed when taking elevation, rivers and roads into account.

Catchment Areas with Facility Services

1 2 3 5 6

HIV Testing/Counseling Pharmacy Laboratory

Boundary
Catchment Area

Comprehensive Facilities: 1. Got Agulu Sub District Hosp 2. Usigu Dispensary 3. Bondo District Hospital 4. St. Annes Dispensary 5. St. Elizabeth Lwak Hospital 6. Anyuongi Dispensary 7. Manyuanda Health Centre 8. Madiany District Hospital
Data Sources Kenya Administrative Boundaries: USAID Famine Early Warning System, 1992 Kenya LandScan Population Dataset: Oak Ridge National Laboratory, 2009 Kenya Road Network: Google Earth, 2010

In this example, catchment areas need to be created for comprehensive facilities (the ones that have all three services: HIV testing, pharmacy and lab). The facility identified where the population they serve lives. Thus, these catchment areas are based on actual data.

Catchment Areas with Total Population 1

Boundary

2
3

Population

4 6
Facility Type
Comprehensive Not Comprehensive

Catchment Area
Catchment Area
Comprehensive Facilities: 1. Got Agulu Sub District Hosp 2. Usigu Dispensary 3. Bondo District Hospital 4. St. Annes Dispensary 5. St. Elizabeth Lwak Hospital 6. Anyuongi Dispensary 7. Manyuanda Health Centre 8. Madiany District Hospital
Data Sources Kenya Administrative Boundaries: USAID Famine Early Warning System, 1992 Kenya LandScan Population Dataset: Oak Ridge National Laboratory, 2009 Kenya Road Network: Google Earth, 2010

Population for each catchment area is calculated and displayed by color. This allows managers to plan the amount of drugs (that require onsite HIV testing, pharmacy and lab) to stock at each facility. For example, more drugs should be allocated in catchment areas 3, 5 and 8.

3. Modeling Walking Travel Time to Nearest Facility

A GIS can calculate how much time one would take to walk across certain terrain, when taking into consideration variables such as slope, access to roads, and impediments like major rivers.
These models can answer questions like:
How many people can walk to a facility within 2 hours? Where are the largest concentrations of people beyond 8 hours?

The example that follow are:

o Calculating Average Distance in Hours by Population

Flatter terrain decreases travel time around this facility, enabling more people to walk to care within 14 hours.

Walking Travel Time Estimates to Nearest Facility from 0-14 Hours

Steep slopes make walking harder and increase travel time to this facility.

This walking time model is easily affected by terrain. Terrain, while not able to be seen on this map, is measured by slope: the steeper the slope, the longer it would take someone to walk across it. Because of the varying slope, facility walking areas are of different shapes and sizes.

Walking Time < 1 Hour 1 2 Hours > 2 Hours

% Population 9.7% 8.2% 82.1%

4. Monitoring and Evaluation

A key utilization for a GIS is for M&E, especially on larger projects that have multiple points to monitor over a large area and for a long period of time. Examples include generating monthly or quarterly maps of projects that want to measure certain indicators:
How has the number of clients who came in to the 10 new VCT centers changed over the past 6 months? Where are the VCT centers that are seeing the most clients? Has there been a decrease in new TB cases in the southern part of the city one month, three months, or six months since the TB awareness campaign started? Which parts of the city saw no improvement in reducing TB cases?

The next slides show:

Example of monitoring condom distribution

In this example, each dispensary was assigned a number of condoms to stock per month to meet the expected needs of the population. One month after the program to distribute condoms started, the data were mapped. Note how very few locations have received more than 50% of their expected number of condoms from the distributor during that month.

After six months, another map was created and shows improvement in distribution. By now, the majority of dispensaries have received at least 50% of the condoms during this month. Several groups of dispensaries received fewer than 50% of the needed condoms that month, so staff can try to address distribution issues specific to those areas.

5. Facility Referral for Emergency Care

Understanding of emergency care systems, such as routing ambulances and identifying referral networks, is greatly enhanced with GIS. A GIS understands road networks and associated speeds to calculate distance as a function of time, enabling researchers to:
View facility coverage areas based on travel time Identify transport time between facilities Model solutions to decrease travel time Find best locations for ambulances, enhancing roads or upgrading health facilities
Modeling Inter-Facility Emergency Referral to Avert Maternal Death and Disability, Ethiopia Modeling Solutions to Reduce Inter-Facility Emergency Referral Travel Time

The examples that follow are:

o o

The GIS recognizes this road network and the facilities that are located on it. It also understands average rates of speed input by the user for each road.

Catchment Areas of Tier As

To identify emergency referral networks from each Tier B to the closest Tier A, the GIS calculated travel time on the roadway for each Tier B facility. This map shows a model of the referral networks (each one is color-coded) based on the shortest travel time. Notice that some Tier As will have many more Tier Bs referring patients than other Tier As.

The green areas have many Tier B facilities that can reach a Tier A facility within one hour.

Total Travel Time from Tier Bs to Closest Tier A Facility

The red areas have many Tier B facilities with a travel time beyond 2 hours.

Each facilitys total travel time to a Tier A is calculated, and is doubled if the Tier B does not have its own transportation. The results show that more than one third of facilities are beyond the desired threshold of a 2-hour travel time (shown as red dots).
Cumulative Minutes to Closest Tier 1 Facility
Under 60 61 to 120 More than 120

Count
77 64 74

Percentage
35.8% 29.8% 34.4%

This is a smaller study area from within Amhara in the previous map. We estimated that 7.5 million people live in this area. According to this model, only 57% of people live near a Tier B facility that is within 2 hours of travel time to a Tier A facility.

Note: The population served by a Tier B facility that is beyond a 2hour drive time (red) indicates that the population that attends that facility is not served by the current referral network.
Total Population of Study Area Population Within 2hour drive of Tier A Facility Percent of Total

7,515,478

4,305,400 57%

One solution modeled is to provide each facility with transportation that does not have it. This increased the population served by 21% and reduced average travel time from 145 minutes to 90 minutes.

Note: The population served by a Tier B facility that is beyond a 2hour drive time (red) indicates that the population that attends that facility is not served by the current referral network.
Total Population of Study Area Population Within 2hour drive of Tier A Facility Percent of Total

7,515,478

5,847,195 78%

Model increased population served by 21%

6. Prioritizing Recruitment for Clinical Trials

Identifying the target population for a clinical trial is crucial. A GIS can be used to assess clusters of target population activity to aid in prioritizing recruitment. Questions answered here include:
Where are the highest risk behaviors taking place? Where should we recruit first? Are there places we should avoid when recruiting?

The next slides show:

o Mapping High Risk Behavior for HIV Clinical Trial

Establishment Clusters by the Average Number of Sex Partners Women Had in Past 4 Weeks

A clinical trial needed to identify the highest risk areas so they could be prioritized for recruitment. Establishments where sex workers were found were clustered together, and their sexual behavior data were averaged by the cluster. One of several variables to identify higher risk areas is a higher average number of sex partners. Two clusters, A and C, stand out as places of higher risk relative to other clusters.

Establishment Clusters by Priority Number

Once the other variables were taken into consideration, the GIS was able to assist decision makers in prioritizing recruitment efforts. Establishment clusters A and C that were at higher risk in the previous map continued to be the higher risk area when other variables were factored in, giving them the first and second priority status for recruitment.

Other Examples
GIS can support research and programs in other ways. Some examples from the literature are listed below.
Identifying statistically significant clusters of high fetal loss and infant death rate due to arsenic concentrations in well water in Matlab, Bangladesh (Sohel 2010) Measuring access to primary health care services in rural South Africa (Tanser 2006) Mapping environmental changes that affect risk of diseases like West Nile virus and Rift Valley Fever in Europe and West Africa (Lambin et al 2010) Community members participated in developing neighborhood maps which strengthened understanding of population served by local health facilities (Ansumana et al 2010) Predicting mosquito habitat for malaria prevention in Zambia (Clennon et al 2010)

Presentations by other researchers can be found online as well at these searchable websites:
Association of American Geographers conference proceedings ESRI Health and GIS conference proceedings

Other Organizations Using GIS

Many other organizations have been using GIS for years in public health research and programs. Several examples are listed below.
World Health Organization
The WHO has developed online tools like HealthMapper to address infectious disease concerns; resources and tools found here

Measure Evaluation at the University of North Carolina at Chapel Hill

Explanation of their GIS approaches for monitoring and evaluation is found here

Centers for Disease Control and Prevention

A map gallery and how they are using GIS can be found here

RTI International
RTI has an expansive utilization of GIS, from survey research and human health risk assessments to cartographic modeling; an overview is found here

John Snow, Inc.

Developed a patient intake form so data are easily integrated into GIS to analyze for disease clusters; an overview is found here

Services: Technical Assistance

ArcGIS Technical Assistance:
FHI 360 has access to ArcGIS software Training is roughly for up to 10 staff for at least 1 week Can be tailored to specific projects Staff learn:
Cartographic Design Map Ethics Basics of ArcINFO 10.3 (GIS Software)
Multiple intensive exercises to get accustomed to the software

Formatting your databases for use in a GIS Basic Spatial Analysis

Contact Information

Caleb Parker
GIS Analyst Behavioral and Social Sciences FHI/NC 919.544.7040 x11487 cparker@fhi360.org