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The geographical accessibility of health services is an important issue especially in developing countries and even more for those sharing a border as for Haiti and the Dominican Republic. During the last 2 decades, numerous studies have explored the potential spatial access to health services within a whole country or metropolitan area.
However, the impacts of the border on the access to health resources between two countries have been less explored. The aim of this paper is to measure the impact of the border on the accessibility to health services for Haitian people living close to the Haitian-Dominican border.
Four scenarios simulate different levels of openness of the border. A linear regression model is also used to predict the accessibility to health care services according to the mentioned scenarios.
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On the other hand, when the border is closed, the potential accessibility for health services is higher for the Dominicans. The openness of the border has a great impact on the spatial accessibility to health lye for the population living next to the border and those living nearby a road network in good conditions. Those findings therefore point to the need for effective and efficient trans-border cooperation between health authorities and health facilities. The geographical accessibility of health services is an important issue in public health and for improved health outcomes, especially in developing countries [ 1 — 6 ].
During the last two decades, numerous studies have explored the potential spatial access to health services within a whole country or metropolitan area [ 7 — 10 ]. Scholars have also analyzed cross-border mobility for health care in pey diverse contexts [ 11 — 24 ]. But fewer studies address the impact of an international border and its openness on the spatial access to health care resources [ 2526 ].
The concept of borders has been evolving throughout the years from their being seen as barriers to their being considered as contact zones, but regional integration and border openness have been questioned in several contexts [ 27 — 32 ].
Studies analyzing cross-border mobility for the use of health care services emphasize the uniqueness of the different border contexts and the importance of the direction of flows [ 1624 ]. Cross-border mobility for health care access may be explained by a variety of factors. It may be motivated by dissatisfaction with health care provision in the home country or by actual deficiencies there.
A lack of coverage in terms of health care insurance or ldy quest for specialized health care may influence individual choice. Affordability, availability and quality of care are 241-6 determinants. Analyzing patient mobility between Laos and Thailand, Bochaton [ 1415 2416-7 demonstrates the importance of well-established mobility practices as well as social networks among border populations in the seeking of cross-border health care.
Model uncertainty in matrix exponential spatial growth regression models
Proximity physical accessibility is also one of the main determinants of patient mobility in the very different contexts of European [ 11 ] and African countries [ 16 ].
Two of these dimensions are spatial: The other three are aspatial and reflect socioeconomic and cultural factors: These dimensions may act as either facilitators or barriers.
Regarding spatial accessibility, scholars define this in terms of the possible use of the services potential accessibility and their actual use realized accessibility [ 3435 ]. This differentiation between potential access and realized access makes it possible to better identify the barriers to or facilitators of access.
The extent of the spatial separation between supply and demand can therefore be analyzed. In this article, we focus on potential spatial accessibility in a borderland context. The border acts either as a geographical constraint or as a facilitator. Our hypothesis is that accessibility varies depending on the level of border openness.
The aim of this paper is to evaluate the spatial accessibility of health care services for Haitians living along the Haitian-Dominican border, and to measure the impact of this border on their health care access using the well-known E2SFCA method.
Both countries have forged and asserted their particular national identities through their respective histories and struggles to achieve the construction of their own nation state [ 3739 ]. The discontinuities territorial, cultural, socioeconomic and political are therefore quite visible at the Haitian-Dominican border [ 4041 ].
An entire apparatus gates, military control on the Dominican side, etc. Officially sincethe border has been opened during the day and closed at night. There are four official entry points and several informal crossing points, the number of which is not precisely known [ 38 ]. These informal crossing points underscore the permeability of the border as well as the complexity of the cross-border mobility [ 43 ].
The flow of the population may be constrained by different conflictual situations: From tothe border was closed a number of times for varying numbers of hours or days. But the intensity and importance of the commercial exchanges for both countries, at different levels, may act as a leverage for conflict settlement.
Cross-border movements from both sides have existed since the colonial period, but Haitian labour flows started in the early twentieth century with the North American occupation of both countries [ 384346 — 48 ].
Various mechanisms are in place in the Dominican Republic to regulate such flows illegality of the Haitian work force, massive deportations, etc. The importance of Haitian labour for the construction industry as well as for the agricultural sector is well documented [ 3843464749 — 51 ]. On the other hand, there is some evidence that the percentage of Haitian immigrants using health care facilities is higher than for other immigrants [ 49 ].
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Furthermore, during the last two decades, the Dominican Republic has been used to channel international aid to Haiti. They consider this to be a factor that could have encouraged a growing number of Haitians to cross the border in search of health care [ 46 ]. Their comments are in line with evidence from other studies addressing cross-border health care mobility in different contexts [ 121516 ].
World Bank Group at databank. Trends in Maternal Mortality: Geneva, World Health Organization, Regional Outlook and Country Profiles, The health care system in most Latin American and Caribbean countries is segmented, with a variety of financing structures and affiliation types. It is also fragmented, with a supply offered by many institutions public and private and facilities that are not well integrated into the health care network [ 52 ].
This fragmentation and segmentation exacerbate inequities in access [ 52 ], which is also the case in Haiti [ 53 ] and the Dominican Republic [ 5354 ]. During the last two decades, both countries—like most Latin American [ 5354 ] and Caribbean countries [ 55 ]—have been involved in an ongoing process of reforming their health care sector.
These reforms are intended to improve health outcomes and to reduce health inequities. They are based on the following principles: Changes have been made in the structure and organization of the public health care system in both countries in order to improve access to health care and especially to primary care. Nevertheless, the pace and the implementation of such reforms have fluctuated from one side of the border to the other [ 55 ].
In the Dominican Republic, the reform has been the starting point for universal access to health care [ 54 ].
Catchment areas have been defined to maximize resource allocation for primary care as well as for equity.
In Haiti, changes have also been made to improve coherence with administrative boundaries and respect for the equity and universality principles included in the health reform [ 60 ]. But the Haitian health system still faces complex organizational and institutional challenges [ 55 ]. As for the Dominican Republic, wealthier and urban people have more access, which means that any form of equity is still largely incomplete [ 6162 ].
Both countries have a three-tiered health care system [ 5657606364 ], but with some specific differences, as shown in Fig. The pyramidal model is organized according to three levels of complexity: The reference and counter-reference system allows patients to transit within the system from the entry point to specialized services when required.
The primary level consists of outpatient services and community care. The first level therefore offers basic health care minimum service package and prevention and promotion activities. One of the main organizational differences between the Haitian and Dominican health care systems is found at this level. In Haiti, the primary level is subdivided into three parts. It includes different kinds of facilities located in distinct territorial entities: However, the official documents are somewhat confusing, as two of them [ 5765 ] consider only two subdivisions and others [ 60 ] mention three.
Moreover, these units offer the same range of services as the first two Haitian first-level subdivisions.
Cross-border spatial accessibility of health care in the North-East Department of Haiti
The facilities of the second level General Hospital in the Dominican Republic, whether administered at the municipal or provincial level, and Departmental Hospital in Haiti offer basic specialized care in both countries. The services offered by the third level cover all contingencies during hospitalization and attend to the most complex cases.
The Haitian health master plan — considers reinforcing coordination with the Dominican Republic in order to reduce health issues in the epidemiological field in the borderland regions. It also seeks to develop relevant strategies and partnerships in the management of infectious diseases. There is a binational agreement for the control of tuberculosis aimed at successful coordination of the actions undertaken in the borderland regions and mainly targeting migrants, the populations of the bateyes settlements around sugar mills where Haitian migrant workers live in very precarious conditions and of the industrial areas, as well as those living in the borderland regions.
In the case of natural disasters floods in and the earthquake inthe Dominican health facilities have supported the Haitian population by offering medical services to those needing them [ 446667 ]. There are also coordinated vaccination campaigns in the borderland regions. But, as far as the official documents of both countries indicate, there is no cross-border cooperation in health care involving any hospitals or other facilities.
They have also witnessed violent conflicts such as the massacre of thousands of Haitians in October This borderland is evolving nowadays from a barrier to a contact zone and an interdependent zone [ 416970 ]. Several stakeholders international organizations, the transnational capital, merchants, grassroots organizations, etc.
The relocation of a private Dominican industrial free-trade zone in the fertile plain of Maribahoux in Ouanaminthe a project financed by the International Finance Corporation however highlights the advantages derived by the Dominican Republic from its different level of development from that of Haiti.
It shows how such disparities are helping to widen the gaps and are fostering more asymmetrical interactions [ 417071 ].
Furthermore, the recent proliferation of binational projects promoted and financed by international organizations is tending to set the framework for a new era of cross-border cooperation [ 41 ] in different fields, including health issues.
The level of poverty is globally higher in the borderland regions of both countries [ 7273 ], but there are still important disparities in terms of infrastructures, services, etc.
As shown in Fig. In the health sector, this intense mobility has forced the implementation of binational mechanisms for epidemiological surveillance. On the other hand, few studies [ 4975 ] have indicated that the ratio of foreigners using health care facilities is higher in the Dominican borderland region compared with the rest of the country.
The high percentage of Haitian migrants It is thus difficult to estimate the percentage of patients crossing the border to obtain health care and the proportion of Haitians living in the Dominican Republic. Dominican health care facilities use for consultation and Emergency by national and foreign patients, Three types of GIS data are needed to assess the potential accessibility of health care services.
To measure the impact of the opening of the border on the spatial access to health care, key consider different scenarios with varying border crossing time impedance: These scenarios are hypothetical, since the level of control is not the same along the border or at the informal crossing points or entry points. Furthermore, different factors objective and subjective influence the smoothness of the flows of Haitians at the Dominican border.