National optimisation of accessibility to emergency obstetrical and neonatal care in Togo: a geospatial analysis

OBJECTIVES: Improving access to emergency obstetrical and neonatal care (EmONC) is a key strategy for reducing maternal and neonatal mortality. Access is shaped by several factors, including service availability and geographical accessibility. In 2013, the Ministry of Health (MoH) of Togo used service availability and other criteria to designate particular facilities as EmONC facilities, facilitating efficient allocation of limited resources. In 2018, the MoH further revised and rationalised this health facility network by applying an innovative methodology using health facility characteristics and geographical accessibility modelling to optimise timely access to EmONC services. This study compares the geographical accessibility of the network established in 2013 and the smaller network developed in 2018. DESIGN: We used data regarding travel modes and speeds, geographical barriers and topographical and urban constraints, to estimate travel times to the nearest EmONC facilities. We compared the EmONC network of 109 facilities established in 2013 with the one composed of 73 facilities established in 2018, using three travel scenarios (walking and motorised, motorcycle-taxi and walking-only). RESULTS: When walking and motorised travel is considered, the 2013 EmONC network covers 81% and 96.6% of the population at the 1-hour and 2-hour limit, respectively. These figures are slightly higher when motorcycle-taxis are considered (82.8% and 98%), and decreased to 34.7% and 52.3% for the walking-only scenario. The 2018 prioritised EmONC network covers 78.3% (1-hour) and 95.5% (2-hour) of the population for the walking and motorised scenario. CONCLUSIONS: By factoring in geographical accessibility modelling to our iterative EmONC prioritisation process, the MoH was able to decrease the designated number of EmONC facilities in Togo by about 30%, while still ensuring that a high proportion of the population has timely access to these services. However, the physical access to EmONC for women unable to afford motorised transport remains inequitable.