For communities in urban and rural areas, access to healthcare facilities is a very significant concern of service delivery to both public policy makers and urban planners. Many healthcare systems set one of their primary objectives to achieve equity and ease of access to healthcare facilities for the populations that they serve. Spatial distribution of population, transport infrastructure, as well as spatial distribution of healthcare facilities are key characteristics that influence the disparities in spatial accessibility to healthcare facilities. Regardless of the permanent interest in transport accessibility, it is often uncertain how different types of accessibility measures relate to one another and which conditions are best for applications. In general, the current study undertakes a statistical comparison among three spatial accessibility measures (representing the main categories of spatial accessibility models) to determine whether they are comparable and/or interchangeable. Specifically, this study aims to use a geographical information system based approach combined with spatial accessibility measures, in a case study, derived from fine spatial resolution datasets, to characterise and divulge spatial variations in individual’s access to healthcare facilities and identify deprived locations/local communities in a selected District Municipality of the Western Cape, South Africa. Results indicate that the main categories of spatial accessibility measures provide different interpretations of accessibility that cannot be reproduced by each other. However, the accessibility measures show a significant similar trend in variations of individual’s accessibility to healthcare services for the communities of Cape Winelands District Municipality. The study establishes that within the Cape Winelands there exist spatial variations in the distribution of accessibility to healthcare and characterises these variations.

Este estudo integrou sistemas de informação geográfica e métodos analíticos geoespaciais baseados em modelos de acessibilidade espacial e de locação-alocação com o objetivo de aprimorar o planejamento espacial de diferentes programas de saúde pública em áreas urbanas. Para estimar a acessibilidade espacial foi desenvolvido o modelo de três passos de área de influência flutuante (E3SFCA - Enhancement three-step floating catchment área) baseado em uma função Gaussiana, considerando um coeficiente de atrito e distâncias ao longo de uma rede de transporte, utilizando o algoritmo de Dijkstra. A metodologia foi aplicada e validada usando os programas de vacinação contra a raiva e de esterilização para cães e gatos da cidade de Bogotá, Colômbia. A escolha do método de cálculo da distância resolveu o problema de superestimação associado com a metodologia clássica que aplica zonas buffer em torno dos locais de serviço baseado em uma distância Euclideana. Em geral, não se encontrou uma adequada acessibilidade espacial aos dois programas. As zonas norte, central e periférica da cidade revelaram baixa ou nula acessibilidade aos serviços. Para determinar a alocação e realocação efetiva dos programas foram utilizados os problemas de máxima cobertura com demanda finita e de p-mediana ou de mínima impedância. A realocação proposta pelo modelo de máxima cobertura forneceu uma melhor distribuição dos serviços nas áreas mais povoadas com cães e gatos e garantiu uma acessibilidade espacial potencial a estes programas. O desenvolvimento deste trabalho pode trazer benefícios diretos para a sociedade em geral auxiliando no planejamento estratégico e melhorando a efetividade das ações públicas em áreas urbanas da América Latina. / This study integrated geographic information systems and geospatial analytical methods based on spatial accessibility and location-allocation models in order to improve the spatial planning of different public health programs in urban areas. To estimate the spatial accessibility, a Gaussian-based three-step oating catchment area (E3SFCA) method was developed, including a friction coeffcient and using distances along a street network based on Dijkstra\'s algorithm. The methodology was applied and valiated using the rabies vaccination and sterilization programs for dogs and cats in the city of Bogotá, Colombia. The choice of the distance calculation method solve the overestimation associated with the classic methodology that applies buffer zones around vaccination sites based on Euclidean (straight-line) distance. In general it was not observed an adequate spatial accessibility to both programs. The zones north, central and peripheral of the city revealed low or no access to services. To determine the effective allocation or reallocation of these programs the maximum coverage with finite demand and the p-median or minimum impedance problems were used. The relocation proposed by the maximum coverage model provided a better distribution of the services in the most populated areas and proportioned a potential spatial accessibility to these programs. The development of this work can provide direct benefits to society assisting in the strategic planning and improving the effectiveness of public policies in urban areas of Latin America.

Este estudo integrou sistemas de informação geográfica e métodos analíticos geoespaciais baseados em modelos de acessibilidade espacial e de locação-alocação com o objetivo de aprimorar o planejamento espacial de diferentes programas de saúde pública em áreas urbanas. Para estimar a acessibilidade espacial foi desenvolvido o modelo de três passos de área de influência flutuante (E3SFCA - Enhancement three-step floating catchment área) baseado em uma função Gaussiana, considerando um coeficiente de atrito e distâncias ao longo de uma rede de transporte, utilizando o algoritmo de Dijkstra. A metodologia foi aplicada e validada usando os programas de vacinação contra a raiva e de esterilização para cães e gatos da cidade de Bogotá, Colômbia. A escolha do método de cálculo da distância resolveu o problema de superestimação associado com a metodologia clássica que aplica zonas buffer em torno dos locais de serviço baseado em uma distância Euclideana. Em geral, não se encontrou uma adequada acessibilidade espacial aos dois programas. As zonas norte, central e periférica da cidade revelaram baixa ou nula acessibilidade aos serviços. Para determinar a alocação e realocação efetiva dos programas foram utilizados os problemas de máxima cobertura com demanda finita e de p-mediana ou de mínima impedância. A realocação proposta pelo modelo de máxima cobertura forneceu uma melhor distribuição dos serviços nas áreas mais povoadas com cães e gatos e garantiu uma acessibilidade espacial potencial a estes programas. O desenvolvimento deste trabalho pode trazer benefícios diretos para a sociedade em geral auxiliando no planejamento estratégico e melhorando a efetividade das ações públicas em áreas urbanas da América Latina. / This study integrated geographic information systems and geospatial analytical methods based on spatial accessibility and location-allocation models in order to improve the spatial planning of different public health programs in urban areas. To estimate the spatial accessibility, a Gaussian-based three-step oating catchment area (E3SFCA) method was developed, including a friction coeffcient and using distances along a street network based on Dijkstra\'s algorithm. The methodology was applied and valiated using the rabies vaccination and sterilization programs for dogs and cats in the city of Bogotá, Colombia. The choice of the distance calculation method solve the overestimation associated with the classic methodology that applies buffer zones around vaccination sites based on Euclidean (straight-line) distance. In general it was not observed an adequate spatial accessibility to both programs. The zones north, central and peripheral of the city revealed low or no access to services. To determine the effective allocation or reallocation of these programs the maximum coverage with finite demand and the p-median or minimum impedance problems were used. The relocation proposed by the maximum coverage model provided a better distribution of the services in the most populated areas and proportioned a potential spatial accessibility to these programs. The development of this work can provide direct benefits to society assisting in the strategic planning and improving the effectiveness of public policies in urban areas of Latin America.

No description available.

Il sistema sanitario ha un ruolo fondamentale nella crescita economica di un paese e per tale motivo è oggetto di continue revisioni, nel tentativo di trovare il giusto equilibrio tra risorse necessarie e risorse disponibili. L’elevata complessità del settore spinge la ricerca scientifica a sviluppare modelli che spieghino al meno in parte l’insieme di attività che costituiscono il processo produttivo al fine di ottenere un miglioramento complessivo nella qualità del servizio offerto. Con questo lavoro viene proposto l’utilizzo congiunto di due strumenti quantitativi, utilizzati in geo-grafia spaziale e in ricerca operativa, che rappresentano in modo dinamico il flusso di pazienti all’interno di una specifica area geografica. / The health system has a fundamental role in the economic growth of a country and for this reason it is subject to constant revisions, in an attempt to find the right balance between resources. The high complexity of the sector pushes scientific research to develop models that explain at least part of the set of activities that constitute the manufacturing process in order to obtain an improvement in the overall quality of the service offered. In this paper we proposed the joint use of two quantitative tools used in geography and space operations research, which dynamically represent the flow of patients within a geographical area.

The growing concern for the shortage of primary care physicians (PCPs) prompted a government legislation to designate areas where shortage in the delivery of primary care services occurs. The implemented systems (e.g., HPSA, MUA, and MUP) analyze utilization of health services within confined administrative units and fail to account for spatial interactions that occur across administrative borders. This research examines the spatial accessibility to PCPs and the underlying demographic and socioeconomic settings. With the Nashville Metropolitan Statistical Area (MSA) as a study area, this study utilized data from the U.S. Census 2000 and 2010, as well as the known locations of (PCPs) collected in 2010. Geographic Information Systems (GIS) provided the tools by which the processing and analysis of the data was carried out. Specifically, network analysis was applied to estimate travel time and service area coverage. A Two-Step Floating Catchment Area (2SFCA) method was implemented to measure spatial accessibility to PCPs. This method was applied to measure accessibility at the level (census block) that most accurately represents the spatial population of the Nashville MSA. In addition, this research implemented several distance-decay functions in addition to the dichotomous function of the standard 2SFCA method. This research has found that the majority of the population residing in the Nashville MSA enjoyed good spatial accessibility to PCPs. However, the highest percentages of those resided in areas of low accessibility were located in periphery rural areas as well as isolated areas poorly connected to the roadway network due to certain physical barriers such as lakes and streams. Moreover, this research has found that, in general, non-spatial factors intensified the most where there was good accessibility to PCPs.

L’objectif de la thèse était de développer un indicateur mesurant l’accessibilité spatiale des premiers soins (nommé Index of Spatial Accessibility : ISA) pour les femmes enceintes, à partir de sources de données collectant des informations en routine. Ce travail a pour vocation de mettre en évidence les limites des indicateurs existants tout en apportant des améliorations. Une attention particulière a consisté à étudier l’impact de l’effet des contours administratifs (ou effet de bord), la limite pointée dans de nombreuses études portant sur l’accès aux soins. L’indicateur d’accessibilité aux professionnels de santé que nous avons développé a pour objectif de mettre en évidence les disparités spatiales à une échelle géographique fine afin d’identifier les zones géographiques dans lesquelles il faudrait intervenir en priorité. Ce travail s’est concentré tout d’abord sur les professionnels de santé intervenant dans le suivi de la grossesse : médecins généralistes, sages-femmes et gynécologues. Les résultats mettent en évidence qu’en combinant la disponibilité avec la proximité des soins, les besoins en matière de santé et la mobilité, l’ISA permet de fournir une meilleure mesure d’accessibilité. L’ISA a été construit afin de pouvoir interroger l’accès aux soins pour d’autres pathologies ou d’autres populations. L’analyse de l’impact de l’effet de bord met en évidence que : 1) la moyenne et l'écart-type sont légèrement inférieurs avec effet de bord que sans, quel que soit le type des professionnels de santé ; 2) La variation d’ISA est plus marquée pour les sages-femmes et les gynécologues, et pour les zones rurales. Nous avons également menée une étude pilote sur le recours aux soins des femmes enceinte, à partir des données SNIIRAM afin d’étudier la relation entre le recours aux soins et l’indicateur ISA. / This paper developed an improved indicator: the Index of Spatial Accessibility (ISA) to measure geographical healthcare accessibility at the census blocks level, and seeks to assess the effect of edge on the accuracy of defining healthcare provider access by comparing healthcare provider accessibility accounting or not for the edge effect, in a real-world application. The indicator of accessibility to health professionals developed aims to highlight spatial disparities measured at a fine geographical scale and to identify area where actions are needed in priority. This work focused first of all on the health professionals involved in the follow-up of the pregnancy: general practitioners, midwives and gynecologists. The main finding is that by combining availability with proximity to services, health needs and mobility, and by calculating at the smallest feasible geographical scale, ISA provides a better measure of accessibility. ISA was conceived so that we could question the access to care for other pathologies and other populations. When we compare the variation of ISA with and without edge effect, we found that (1) mean and standard deviation are slightly below when offer and demand outside are taken in to account, whichever health professionals considered; 2) the variation of ISA is higher for midwives and gynecologists, and for rural areas. In addition, we also conducted a pilot study on the health use of pregnant women, using SNIIRAM data to examine the relationship between use of care and the ISA indicator.

Cette thèse s'intéresse à la réconciliation entre le défi mondial du changement climatique et les solutions locales et sectorielles qu'il convient de bien articuler pour contribuer, efficacement, équitablement et de la manière la plus acceptable, à la réduction des émissions de CO2. Plus précisément, nous étudions les conditions pour une mise en place réussie de la politique climatique à l'échelle de la mobilité urbaine des personnes. / This PhD thesis deals with the reconciliation of the global challenge that is climate change and the local and sectoral solutions that need to be accurately designed to remedy to it the most efficiently, equitably and acceptably possible. More specifically, we investigate the conditions for a successful implementation of climate policy at the scale of the urban mobility of passengers.