A Web Gis For Health Services Delivery

Published Date: 02 Nov 2017

This study was aimed at designing and implementing a Web based GIS as a spatial decision support tool to assist the planning of health services delivery in Papua New Guinea (PNG). In this study, particular focus was on health infrastructure data as they are the main interface between any health service delivery system and the population it serves. As objectives of the study, the following were accomplished: a requirement analysis, tools and software review, spatial database implementation and a web client application development. Important investigations carried out alongside the main objectives of the study included the assessment of viable solutions to Web GIS application development for developing countries, the non programming options for developing simple and user friendly applications and web client application design options and approaches.

To facilitate the implementation of the workflow procedures typical to any Web GIS Application Development, this study has explored the use of Free and Open Source Software (FOSS) products as well as freeware(s). The following software tools were used: PostgreSQL 9.2 (PostGIS) as the RDBMS, GeoServer 2.2 as the application server, Apache Tomcat 6.0 as the web server. The development of the client involved the use of OpenLayers 2.12 API, GeoExt 1.1, Extjs 3.4.0 and Heron 0.7 configuration. This study has resulted in the development of a simple Web based GIS application prototype featuring health infrastructure data with the aim of assisting the planning of health services delivery in Morobe, Madang and West New Britain provinces in Papua New Guinea.

Keywords: Web GIS, Geodatabase, Health Infrastructure, Health Services Delivery

TABLE OF CONTENTS

LIST OF FIGURES

LIST OF TABLES

ACRONYMS

API - Application Programming Interface

FOSS - Free and Open Source Software

GIS - Geographical Information System

GoPNG - Government of Papua New Guinea

NDoH - National Department of Health

OGC - Open Geospatial Consortium

PNG - Papua New Guinea

RDBMS - Relational Database Management Systems

1. INTRODUCTION

1.1 Overview

Improving health services is vital to achieving Millennium Development Goals in most developing countries. Delivering health services have been a major challenge for most developing countries both in the past and present (Peters et al., 2009). While the specific cause of this may vary from region to region, the common driver of this problem can be attributed to ill governance and its flow-on effects. Depending on how information is being used, good governance should be based on sound information system.

A major problem faced by most developing countries especially in the case of Papua New Guinea is the poor management of health services related data, in particular, that of health infrastructures. In most cases, the time, effort and resources allocated to the recording and collecting of information becomes a waste as there are no proper information management mechanisms in place.

A proper information system has to be spatially enabled, and designed to capture, store, manipulate, analyze, manage and enables easy visualization of patterns and trends in the data. Essentially, this is referring to a Geographical Information Systems (GIS). To the data administrator, GIS can provide a one-stop workable solution to managing the data. To the end users of information especially health planners and policy makers who try to solve health service delivery problems, GIS helps to provide solution because it enables the spatial component of the problems and leverages target intervention.

Amongst some of the crucial information which health planners and policy makers should be aware of is the spatial distribution patterns of health infrastructure and accessibility by the population across any geographical region (Marcus and Makanjuola 2011). This is due to the fact that Health facilities including hospitals, Urban Clinics, Health Centers, Sub Health Centers and Aidposts are the main interface between any health system and its population. However having such information in paper records and excel spreadsheet makes spatial visualization of patterns and trends difficult to achieve.

As stated by Tereshenkov (2009), the increasing number of spatial data users in both the public, private and civil society means that there is a need to provide wide public access to geographical data. The good news being that this can be achieved through the Internet - a worldwide network of many different computer networks. Now that the sharing of spatial information via the internet is feasible, this requires the development of efficient, cost-effective, scalable, and effective GIS applications that can satisfy the needs of the users.

The primary aim of this study is to design and implement a Web GIS as a spatial decision support tool to assist health service delivery in Papua New Guinea. In this study, primary focus is on health infrastructure data as they are the main interface between any health service delivery system and the population it serves.

1.2 Thesis Structure

This thesis paper is divided in five major chapters. Chapter 1: Introduction - comprises of the study overview, problem statement, significance of study and study aim and objectives. Chapter 2: Basic Theoretical Background - provides details on basic theoretical knowledge surrounding Web GIS and its different components. Chapter 3: Study Area - provides a description of the study area in terms of the country and the selected provinces within that were chosen for the prototype. Chapter 4: Methodology - provides a description of the study area and the actual workflow procedures in accordance with the objectives of the study that were implemented. Chapter 4: Results - provides details on the main results as achieved from the workflow procedures from chapter 3. Chapter 5: Discussion, Conclusion and Recommendation - this chapter provides a discussion of the results, makes a conclusion as well as recommendations for future related studies. Figure 1 below shows the thesis structure diagrammatically.

Figure 1 Diagrammatic illustration of the thesis structure.

1.3 Problem Statement

The Papua New Guinea National Department of Health is a statutory body with the mandate of ensuring effective and efficient timely delivery of health services to the people/beneficiaries. Figure 2 below shows the organization structure of the National Department of Health, emphasizing the two sub-departmental sections that are relevant to this study.

Figure 2 PNG National Department of Health Organizational Structure

Following the introduction of the Organic Law on Provincial and Local Governments revised in 1995, decentralization was introduced where there was a significant change in the structure of health management functions. This meant that the districts and local level government were given full powers to manage their own health service delivery functions. The National Department of Health is responsible for policy, standards, training, medical supplies, specialist services, public hospitals and monitoring, while the provincial and local governments are responsible for rural health service delivery in terms of implementation of health policies, standards and funding programs. This further meant that provinces are responsible for the administration and routine maintenance of all rural health facilities. The responsibility includes the delivery of basic services like drug distribution, health patrols, immunizations and obstetric care. Figure 3 below shows the Health Service Delivery Function Assignment between the different levels of government as dictated by the Decentralization Policy.

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Figure 3 Health Service Delivery Function Assignment between the different levels of government

1.3.1 Issues with Health Services Delivery

Despite the huge amounts of cash pumped in to the health sector by the government of Papua New Guinea and donor agencies to drive the implementation of health programs and plans, the amount of health expenditure has fallen and the country continues to plunge in terms of health indicators. Operational problems include: low standards of patient care, unhealthy workplace practices, run-down and inadequate facilities and equipment, and inappropriate distribution of healthcare staff. While the provincial hospitals serving the urban population and managed by the NDoH have developed in terms of specialized services with variable quality, the major shortfall is concerned with the delivery of primary health care services to the rural masses.

The current poor health status experienced by the rural populations indicates a defunct primary health care system with ineffective and inefficient delivery of essential services to the rural communities. This can be said to be a negative flow on effect of the decentralization policy where the provinces and districts were given the responsibility to manage rural health services without inadequate resources like financial resources, decision support tools and managerial capacity.

According to WHO Country Corporation Strategy 2010 – 2015 paper, the main barriers to accessibility to health services include geography, finance, human resources and poor quality of service. PNG with its rugged terrain increases the challenge of cost for the delivery of health services and accessibility by the population. The geographical isolation as well as closure of some rural aid posts caused a lot of patients from remote areas to travel significant distances in poor road conditions to access health services. Additionally, most rural health facilities have closed down or are defunct. Where services are still being provided, they are of poor quality. The scarcity of health care workers in rural areas is also another major factor affecting access to quality services. The overall health workforce in PNG remains lower than required for the country’s population.

With over 80% of the population living in rural areas, strengthening and improving primary health care is of utmost importance. The decline in the delivery of health services is indicated by an increasing number of defunct and run down rural health facilities, inefficient medical supply distribution and inadequate resources at the health centre and aid post level to deliver the basic services which are prerequisites to improving health outcomes.

Three levels of health workers responsible for the delivery of primary health care services are the nursing officers, HEOs and community health workers. The rural health facilities are the Sub Centers, Health Centers and aidposts. To top it all, the current information systems focus more on the reporting protocols between the different levels of government other than centralized storage, management, analysis and retrieval of data for timely and reliable decision making.

1.3.2 PNG National Health Information System

Even before independence in 1975, Papua New Guinea had some form/level of health information systems which is more a reporting system with focus on providing information to program managers at the national level. However the decentralization of health services delivery functions to provinces in 1983 saw an increased demand for information at the provincial levels by provincial health managers to plan and monitor health programs. As a result, provinces were also given the responsibility to manage their own information systems/reporting systems. By 1994 it became evident that there were emerging differences in the data that each province collected which made it difficult to analyze and interpret information on a national scale. Due to these discrepancies, the Government of Papua New Guinea (GoPNG) standardized its health information systems with funding and technical assistance from the Asian Development Bank (ADB). This meant that the reporting system was standardized across the board for all the provinces. At the same time, a national inventory of existing health facilities was done to gather information on staffing, buildings and equipment at the facility level.

A major consequential set back was that the use of information became weak at the National level partly due to the challenges in obtaining a national data set. To address this issue, provinces were expected to provide feedback as a way of putting their performance into perspective by comparison with other provinces. Feedback included information on Family Health Indicators since it was always readily available and considered important. At every annual provincial health managers meeting, information on Family health indicators were used to compare provincial performance in terms of information recording and use. This activity had a positive impact on the quality of reporting. Within the context of a standard reporting system, the GoPNG has benefitted from this National Health Information System.

One of the main aims of this exercise on standardizing the reporting system is to ensure that the lower levels of management will use the information for planning and monitoring their health services delivery functions. However, it was realized that an important way of promoting this trend is by setting a good example at the National levels. If senior management at the National levels actively looks for information and uses it then the importance of information is strengthened throughout the health system. So far, information at varying levels of quality has been used to defend the position of the health sector in interdepartmental negotiations and to persuade donors to conform to government priorities. This has given a bigger purpose for the health information system and helped to enforce requests for data. When data is used at the top management levels and actively disseminated it creates a workable environment to develop information use amongst middle management and health workers.

1.3.3 What is lacking?

Regardless of the good sides of the standardized National Health Information System that was established between 1994 and 2000, little has changed over the years to accommodate the changing trends of information requirements. On the other hand, this National Health Information System is more of a manual "standardized-reporting-system" with all focus on standardizing forms and templates used at the provincial levels during information recording. Without understating the importance of any standardized way of information collection, how these data are centrally captured, stored, managed, analyzed and retrieved from a proper computer based data and information storage system are also of utmost importance and is still lacking. There are several data storages within departmental sections and provinces that do not communicate well with each other to meet new demands of information among the public and private health sectors. The changing trends of information requirements means that there is a need to start focusing on "information technology (IT)" oriented ways of managing data for wider real time distributed access.

The major shortfall in Papua New Guinea's state of health services concerns the delivery of primary health care services to the rural population whom are served through rural health facilities. While this is due to a variety of other reasons, this study aims to tackle the problem from an information management and access perspective for better decision making. Ideally, if information is managed and used effectively at the top levels of management for decision making, this should have a positive flow-on effect on the beneficiaries of health services in rural areas. Since both health facilities and population have geographic space, it is only reasonable to capture every information on a per health facility basis. Whether it is disease, staffing, population, equipment, medical supplies and performance, all these information should be spatially captured per health facility in order to attach more importance to the facilities.

The current state of the health information system does not address several issues:

Wider information needs to keep up with changing business processes of the health sector,

importance of health facilities,

it is not spatial which makes holistic visualization of patterns and trends difficult to achieve and therefore does not leverage target intervention,

it does not clearly reflect the geographic constraints of services delivery,

it does not support central management of data and distributed access in such a way that information is centrally managed but varying levels of authentication given to all stakeholder including provincial health offices to update and access information to support their health service delivery functions. In this way, relevance and importance are attached to information at all levels of government because each level has a responsibility to play towards data management.

To this date, a GIS based health information systems is still non-existent. Additionally, to strengthen collaborations among wider groups who are concerned with and are tasked to assist GoPNG with the implementation of health plans and programs there is a real need to incorporate GIS into the existing information systems. Further to that, there is a need to take on approaches that supports wider information access which can be achieved through the internet and the world wide web.

1.4 Significance of Study

The primary significance of this study is to do with 'promoting of technology and wider information access in a country where the use of GIS is still at an infant stage or non-existent at least in the health sector. Introducing new ways of doing things is always not easy for three main reasons as predicted in the case of PNG. First of all, officers in the respective government departments are used to conventional ways of doing things and might not easily adopt change. Secondly, changes can also lead to either cutting down of tasks or even modification to tasks job descriptions which may not favor current employees. Thirdly there is always the excuse of not enough funding to cater for new requirements, infrastructure and maintenance support for the sustainability of such technologies in the longer term. However if we are to move forward, we have to address the issue of changing information access and management requirements coupled with the supporting technologies that are seen to support health services delivery in other parts of the world. While further discussions on the above mentioned change resistances is beyond the scope of this study, they are identified as some of the issues of consideration in the event of any future GoPNG projects concerned with revamping of its departmental/sectoral information systems.

It is envisaged that this prototype application as developed in this study using FOSS and freewares can be used as a feasible starting point to first of all promote the benefits of GIS in the health sector and secondly as a base for further improvements. This is aimed at triggering the necessary discussions and actions by the GoPNG, National Department of Health and relevant agencies that are responsible for ensuring smooth delivery of health services. Secondary significances of study include promoting wider access to useful information for health services planning and sharing of knowledge and experience to those who want to implement similar application to help service delivery in their country.

1.5 Study Aim and Objectives

Aim

The overall aim of this study is to design and implement a Web based GIS as a spatial decision support tool to assist Health services delivery in Papua New Guinea.

Objectives

To achieve the overall aim of the study, the specific objectives were set:

Carry out a requirement analysis

Review available tools and software and gather them for the research.

Develop a spatial database of the country’s health facilities to facilitate proper management and easy access to health facilities related information.

Design an application for publishing the data on the web for wider information access.

2. BASIC THEORETICAL BACKGROUND

The growth of Web Services technologies and data interoperability standards has resulted in the development of new applications and innovative data sharing techniques. Web based GIS applications are an example of this advancement in internet technologies. Within this context, the term 'web-based' can refer to the data or the software or both. In terms of the data, this means that the client accesses the data via OGC protocols like Web Map Services and Web Feature Services using Desktop GIS Software. In terms of the software, this means that the client accesses the data via a web browser based client application. For the output of this study, both the data and software is web based. The aim of this chapter is to provide the basic fundaments of Web GIS that are necessary to understand the nature of this study in terms of its implementation approach.

Internet and the World Wide Web

As defined by Dyson (1997), generally the Internet is a massive networking infrastructure that globally links millions of computers together. This facilitates the communication between any 2 or more computer as long as they are all connected to the Internet using the Transmission Control Protocol/Internet Protocol (TCP/IP).

The World Wide Web is a way of sharing and accessing information through the internet. The Web uses the Hyper Text Transfer Protocol (HTTP) to transmit data over the internet. The HTTP essentially provides a mechanism whereby a client requests a document and a server sends that document. Services using HTTP to allow applications to communicate to exchange business logic use the Web to share information (Weinberger 2002).

Web GIS

Web GIS refers to developing GIS functionality in the Internet, Worldwide Web, and private intranets. Web GIS is capable of distributing geographic information to a very large worldwide audience which means that users of the internet access GIS applications from their browsers without having to buy commercial GIS software (Kenneth and Kirvan 1997). As mentioned previously, the OGC protocols like Web Map Services (WMS) and Web Feature Services (WFS) have made it possible to distribute geographical information via the web. The main challenge of Web GIS is the development of software systems that are platform independent and can run on any computer connected to the Internet (or any TCP/IP-based network) supporting a Web browser. This is a revolution to the traditional way of operating commercial GIS software over local-area networks (LANs) or intranets on just a few types of computer hardware. There are 3 approaches used to add GIS functionality to the Web. The Server-side allows users (clients) to submit requests for data and analysis to a Web server.  The Web server then processes the requests and responds by returning data to the client. Client-side allows the users to perform some data manipulation and analysis locally on their own machines. Hybrid strategies or the Client-Server approach is where the Client and Server processes can be combined to maximize performance and meet special user needs (Tereshenkov 2009). Developers of Web GIS can program their applications from scratch or they can now, as in most cases, purchase the necessary GIS modules from commercial vendors. Some of the advantages of Web Based GIS to government authorities include: sharing of data by the departments, centralized data storage and management, services are joined-up and the holistic view of data to ensure holistic decision making.

Web GIS Architecture

Generally there are two main types of Web GIS Architecture: the two tier client server architecture and the three tier client server architecture. The two tier architecture is made up of the client side software and the server side software. When there is a communication protocol between the client and server, this on-set the transfer of spatial data from server to client where the client software facilitates visualization of spatial data while the server software only offers database service (Luqun et al., 2002). The three tier client server architecture comprises three different logical levels. The first level is the user interface (client). The second level is the business logic level which does the GIS transaction processing. The third level is the GIS data storage service which is responsible for the continuous storage of functional data. The Client side comprises the web browser e.g. Firefox or Internet Explorer. The business logic usually is made up of the HTTP Server or Web Server e.g. Apache and the Application Server or Map Server e.g. ArcGIS Server or Geoserver. The data tier can be made up of Database Management System (DBMS) Server e.g. PostgreSQL or SQL Server. According to Peng 2001, the three tier architecture has 3 main advantages: better performance, scalability and security.

A Web server is designed to handle the HTTP protocol whereby when it receives an HTTP request, it sends an HTTP response back as an HTML page. In response to a request, a Web server may return a static HTML page or image, send a redirect, or assigns the dynamic response generation to some other program such as CGI scripts, JSPs (Java Server Pages), servlets, ASPs (Active Server Pages) and server-side JavaScript (Martin 1996). A Map Server, as the name implies, is a server that provides web maps. A Database Management System (DBMS) provides a means of storing and managing data in a way that allows user to share data in a database. Core functions of a DBMS include: (i) managing CPUs, network and disk drives that store and process the data (ii) offering transactional ACID (Atomicity, Consistency, Isolation, and Durability) properties to ensure users have proper view of data (iii) provide high performance algorithms that can perform both simple and complex tasks, and (iv) augment performance by choosing the correct algorithms to execute queries (McWherter 2008). Most GIS databases are embedded inside Object-Relational Database Management System (ORDBMS) which extends the Relational DBMS to handle GIS objects.

Client Side Applications

The overall design of the Web GIS user interface must be carefully designed in such a way that users can understand and make use of the information and functions provided by the system. A desktop application provides a richer user interface experience where the GIS user can retrieve data and perform spatial analysis or other processing. In this case, the desktop client can either connect directly to the geodatabase on the database server through direct-connect drivers or make a request via the http protocol (Dean 1997). For example, in ArcGIS, it means that the ArcSDE libraries and drivers are installed to facilitate this connection. An alternative for accessing hosted information is through Web browser which is usually limited however there are possibilities to offer dynamic maps via the web through what is called an Application Programming Interface (API). An API is a group of programming instructions and standards for accessing a web based application or tool. For example, ArcGIS JavaScript API, ArcGIS FLEX API, Microsoft Silverlight or OpenLayers API can allow developers to create dynamic applications with the functions of combining data from different sources and content (Tereshenkov 2009).

Web GIS Application Development Cycle

The application development cycle can be said to be organization and project specific however in terms of a Web GIS, the following diagram shows a well detailed model according to Allesheikh et al., 2002 that can be easily adopted.

Source: Allesheikh et al., 2002

Figure 4 Web GIS Development Cycle

The requirement analysis can be done through surveys with the users to determine user desired functionality, data layers, data attributes, user skills and spatial literacy. Based on the results of the requirement analysis, the conceptual design is drawn up which is basically the data model that identifies the entities and their relationships. Identification of suitable software to use is vital in the successful implementation of any web development process. Software can be evaluated for functionality, performance and cost. Web GIS involves the transfer of huge volumes of data hence issues of bandwidth and internet connection speed is important. The database design and construction phase is when the actual logical and physical design of the database is drawn up. Upon completion of the database design and construction, the necessary software and hardware identified will be purchased or sourced. The next step is to integrate the different components of the hardware and software and to test them to ensure they work as expected. Upon successful hardware/software system integration, the Web GIS application is then developed. The complexity of this phase is dependent upon the user desired functionality as specified in the requirement analysis phase. The final stage is to test the application to make sure it works as envisaged before releasing to the users.