A GIS-based Transport Network for Emergency Referral in Bangladesh

Access to basic healthcare services is a cardinal human right, enshrined in the World Health Organization’s Constitution, which envisions the “highest attainable standard of health as a fundamental right of every human being”. Comprehensive, quality healthcare services are critical not only for treatment, but also prevention and management of illnesses which culminates in reducing unnecessary death and injuries and increasing overall life expectancy.

Globally, millions of people face challenges accessing adequate healthcare services, with those living in rural settings the most affected. One of the key components of healthcare is timeliness in availing these services, including access to a location with adequate healthcare provisions. More recently, the Sustainable Development Goals have also emphasised the importance of expedient access in Goal 3.8 which seeks to provide “access to quality essential healthcare services”.

In general, there are three types of delays in a healthcare system which can negatively affect the patient’s life. These include a delay in decision to seek care; delay in reaching a health facility; and delay in receiving appropriate treatment. These blockages in the system are almost always prevalent in countries with poor socioeconomic conditions, such as Bangladesh.

Geographical factors are one of the primary deterrents to establishing a thorough referral system, one which is connected through local transports. Recommendations proposed by UNICEF state that in low- and middle-income countries (LMICs), geographical conditions can be used to regulate the accessibility of villages and the types of vehicles to be used specifically for each terrain.

However, the healthcare system in Bangladesh is not adequately equipped to provide transport facilities in emergency situations. This gap in services rendered increases the delay in reaching a health facility, and for many patients, it is a matter of life and death. To address this issue, scientists at icddr,b have developed a geographic information system (GIS), tailored to Bangladesh’s climate and topography, to transcend geographic barriers and identify the fastest route to the nearest health facility.

While there have been many studies exploring the utilisation of GIS in the referral system, very few have been conducted in the context of LMICs. Moreover, icddr,b scientists endeavoured to develop a transport model which can solve two existing problems with the current healthcare system. First, it can address the uncertainty of transporting patients facing emergency conditions thereby reducing the delays in finding a transport. Second, it can increase people’s willingness or compliance in availing life-saving healthcare services, thus solving the issue of delays in making healthcare related decisions.

To test the model into practice, icddr,b developed a transport system for emergency referral of sepsis patients to guide them to the nearest transport hub or sub-hub and subsequently transfer to the nearby health facility. Suspected patients would call the 24/7 ‘Sepsis Call-in Centre’ which was linked and coordinated with the transport system.

The call-in centre would then assess the patient’s symptoms and if referral was necessary, access the GIS database to guide the patient on how best to utilise the available roads and transports to reach their destination (Figure 1). Furthermore, the patient’s estimated arrival time would be communicated to the healthcare facility from the referral point so that they faced no delay and received care immediately upon arrival.

Figure 1: The operational schematic of the emergency referral transport system. Dotted lines represent the processes that directly employed information from the GIS database.

Figure 2: Percentage of zonal compliance with the referral advice during the four semesters of the study period. Polynominal and linear trend lines show the compliance pattern from the red zone.

This model has demonstrated great promise. Compliance with the referral decision increased significantly, especially in the ‘red zone’ – the most remote areas with a travel time of more than 50 minutes (Figure 2), denoting that a competently operated existing transport system can boost a patient’s inclination to capitalise on life-saving treatment.

This comprehensive guide on developing an organised emergency referral transport system by efficiently utilising the existing resource settings has the advantage of not only preventing unnecessary expenditures through purchase of new vehicles, but also providing constant and consistent availability of transport which are adaptable to the local terrain. Furthermore, the icddr,b GIS model can identify service gaps and unsuitable routes when transporting patients, ensures access to healthcare for those in residing in remote locations, and guarantee transport services which are adaptable to the weather and climate.

Atique Iqbal Chowdhury, one of researchers in the team and the key GIS-personnel states that “in Bangladesh, delays associated with the timely transportation of patients to health facilities remains a great challenge. This GIS-based transport model solves uncertainties with transport availability, offers the fastest route to hospitals and can be used to reinforce ambulance services. This ultimately saves lives of those in emergency conditions”.

Applying this GIS-based transport system is not without challenges. The model heavily relies on GIS analysis to identify the shortest route to nearby health facilities and insufficient spatial data (e.g. road network database, village boundaries, location of health facilities and transport hubs, geographical barriers, and travel time algorithm for different modes of local transport) is a critical obstacle which needs to be overcome for this system to operate efficiently.

The invention of icddr,b’s GIS-based transport network model could be instrumental in ensuring those living in rural and remote settings are able to have proper and timely access to healthcare services. This holistic model can be utilised to address any emergency medical cases in Bangladesh and if properly adapted, across inaccessible areas in many parts of the world.

A delay in detection and treatment can negatively impact one’s health, as well as possibly incurring further costs. Those who have a consistent source of care can expect to have better health outcomes, less disparity and reduced financial burden from medical and health expenses.



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14 replies »

  1. I read down, but couldn’t quite grasp your reference to a referral system and really couldn’t grasp what you were looking for.

    A referral system can mean many things. Margalt likened it to a triage center but I don’t know if you meant that either. Medicare HMO’s have used nonphysician staff to respond to emergencies and some have caused delays in treatment. Are you looking for a different type of referral system?

    There are some people that are unable to care for themselves so perhaps you might be alluding to that specific group in your last reply.

  2. I once saw a person who had been on an ocean cruise from Seattle to Anchorage. During the cruise, he had an MI. Since it was his second episode, he went directly to the ship’s dispensary. A nurse gave him two aspirin and called the nearest coastal 911 center for a helicopter. They arrived in about 10 minutes and took him to the small regional triage location where an ECG verified an MI as read in Anchorage, given his IV thrombolytic (within 27 minutes following onset of sx according to EMS report given to my patient), observed for 1/2 hour, flown to Anchorage for a heart cath and a CABG the next day. Important is that the triage center arranged the pickup directly with the ship’s Captain based on the coastal surveillance system. Obviously, this was all seemingly routine since no one goes anywhere quickly in Alaska without getting on some type of airplane, year around.
    Parenthetically, the maternal mortality ratio for Alaska as well as Massachusetts has ranked within the 6 States with the best Maternity Mortality Ratio for the last 30 years, the only two states with that achievement. No doubt, Social Capital at its best.

  3. We have many people hours away from medical care too (like in the Sawtooth National Forest)….but many fewer people far away from sheriffs, firemen, policemen, schools, bus, train and airport hubs and government offices. We could train a lot of these latter people in rustic urgent care in these other places and supply many of these facilities with essential ER medications and medical equipment….if we were not so tight with all our licensing regulations.

    How hard would it be for a sheriff or a school principal to start a little Ringers’ lactate and antibiotic in a septic patient? …with a few hours of training?

  4. Are you implying that using a helicopter for trauma cases that reduce the time it takes for the injured to get to the operating room at a trauma center is a waste of money?

  5. Forget triage. I want a national database that tracks people who need referrals and periodic check ins ..

  6. So you want people to call a triage center before they call 911 or their doctor? Are you sure that’s better than what we now have, or just better than Bangladesh? Be careful what you wish for b/c they may just do that to Medicaid folks…

  7. Forget the GIS part. Think “referral system.” Some examples of things a referral network could handle: opioids, at risk behaviors, hypertension, diabetes

  8. Exactly my point. American technologies are expensive. We’re not so good at cheap stuff that just works.

  9. Based on the numbers I’ve seen they don’t seem to be doing a very good job, lots of money, resources etc wasted

  10. via TweetBot

    Oh…. I don’t know…. maybe because we have 911, ambulances, paved roads, helicopters and trauma centers galore….. 🙂

  11. Could a simple referral technology developed for a struggling developing country have applications in a country like the U.S?

    I think it just might.

    Why doesn’t CMS have this?