Beyond distance: an approach to measure effective access to case management for sick children in Africa.

Health planners commonly use geographic proximity to define access to health services. However, effective access to case management requires reliable access to a trained, supplied provider. We defined effective access as the proportion of the study population with geographic access, corrected for other barriers, staffing patterns, and medicine availability. We measured effective access through a cross-sectional survey of 32 health facilities in Malawi, Mali, and Zambia and modeled the potential contribution of community case management (CCM). The population living within Ministry of Health (MOH)-defined geographic access was 43% overall (range = 18-52%), but effective access was only 14% overall (range = 9-17%). Implementing CCM as per MOH plans increased geographic access to 63-90% and effective access to 30-57%. Access to case management is much worse than typically estimated by distance. The CCM increases access dramatically, again if providers are available and supplied, and should be considered even for those within MOH-defined access areas.