Atlas of health infrastructure for the Mbeya Region in Tanzania Regional atlases as information source using geoinformation systems

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1 Journal of Maps ISSN: (Print) (Online) Journal homepage: Atlas of health infrastructure for the Mbeya Region in Tanzania Regional atlases as information source using geoinformation systems Jürgen Schweikart, Conrad Franke & Stefanie Henke To cite this article: Jürgen Schweikart, Conrad Franke & Stefanie Henke (2014) Atlas of health infrastructure for the Mbeya Region in Tanzania Regional atlases as information source using geoinformation systems, Journal of Maps, 10:4, , DOI: / To link to this article: Jürgen Schweikart Published online: 08 May Submit your article to this journal Article views: 373 View related articles View Crossmark data Citing articles: 2 View citing articles Full Terms & Conditions of access and use can be found at

2 Journal of Maps, 2014 Vol. 10, No. 4, , SOCIAL SCIENCE Atlas of health infrastructure for the Mbeya Region in Tanzania Regional atlases as information source using geoinformation systems Jürgen Schweikart a, Conrad Franke a and Stefanie Henke b a Beuth University of Applied Sciences Berlin, Berlin, Germany; b German Society for International Cooperation (GIZ) GmbH, Tanga, Tanzania (Received 18 September 2013; resubmitted 23 January 2014; accepted 9 February 2014) The Ministry of Health and Social Welfare of the United Republic of Tanzania is the publisher of the first Health Atlas, Health Service Availability in the Mbeya Region Tanzania. This atlas shows a comprehensive picture of the health infrastructure in the Mbeya Region in Tanzania. A variety of indicators for health care on the level of the supplying institutions is visualised with the help of thematic maps. The displayed information concerns the availability of health services in rural areas and gives an impression of spatial disparities. The atlas is a product of a geographic information system introduced in the region, where the contents are presented cartographically outside of the digital system in a clear manner so that they are accessible to a wider audience. Keywords: health atlas; infrastructure; Tanzania; geoinformation systems; atlas of health; Mbeya region; availability 1. Introduction Atlases are one of the most important products in the field of cartography. Whilst the printed format was predominant in the past, the digital medium has forged ahead over the last 30 years as an alternative. Today, atlases are used to track numerous targets, which exceed geographical orientation. The representation of regional and thematically confined content is one of the essential advantages of an atlas. These advantages are increasingly recognised beyond the field of cartography (Ormeling, 2009) and have found useful application in almost all scientific fields where subject matter is set in a geospatial context. Amongst these are topics related to the social sciences (Lentz & Ormeling 2008) that depict our cultural and natural heritage (El chaninov, 2007) as well as issues in the health sector. In the Mbeya Region, in the southwest of Tanzania, a Geographic Information System (GIS) is being implemented in the health sector (Health-GIS). The region has eight districts with a total size of 62,420 km 2 and a population of 2,707,410 people (NBS, 2013). The aim of the project is to create a tool for decision makers, which enables a quick and effective overview of all relevant Corresponding author. schweikart@beuth-hochschule.de This work was supported by Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH. Eschborn, Germany # 2014 Jürgen Schweikart

3 Journal of Maps 621 aspects regarding regional health facilities. Furthermore, it should help to plan and create steering opportunities. Therefore, health facilities ranging from dispensaries to hospitals have been captured, geo-referenced and equipped with attribute data (Schweikart et al., 2009). In view of the planned decentralisation of health services (Ministry of Health and Social Welfare of the United Republic of Tanzania 2008), a technically reduced form of GIS will be introduced in the eight districts of the Mbeya Region. A selection of data has been published in the print edition of the Health Atlas, Health Service Availability in Mbeya Region Tanzania (Ministry of Health and Social Welfare of the United Republic of Tanzania 2010). As a result, the Health-GIS project has been brought closer to the general public in a manner that is more easily archived. This makes it easier to draw future comparisons and to review advancements within the healthcare services implementation of a spatial database system of healthcare information. The Health Atlas is an important medium for the visualisation of living conditions in the Mbeya Region. The maps provide planners and decision makers with a better understanding of the captured data and their spatial context. Whereas GIS is only available to a relatively small group of people, the printed atlas is clearly capable of reaching more people, particularly as it is obtainable free of charge to all employees of governmental health facilities. Thus the general increase in demand for information about public health in the region is satisfied. The atlas is targeted at individuals working in public health, those active in planning and supervisory capacities, and for all those interested in public health issues. Based on the educational and professional background of this target group, it is expected that they have prerequisite knowledge of the content and are competent in elementary cartography. However, intercultural distinctions have to be considered, as the communication between map producer and map user can be handicapped if they do not use the same code due to their contrasting backgrounds (Domnick, 2005a: 6). Knowledge about visual, geospatial and cartographic perception and communication within the target groups is necessary to produce these maps (Domnick, 2005a). This is principally supported by development, research and collaboration, providing the parties participation in the working and decision process (Domnick, 2005b). For this reason, there was close collaboration with the Tanzanian colleagues and users in the process of map design during the production of the Health Atlas. 2 Data and Methodology 2.1 Concept The Health Atlas of the Mbeya Region is structured in the following format: after a few introductory words, a topographic overview of Tanzania and the Mbeya Region is given. The main part is subdivided in district and regional maps, as well as maps of the whole country. All data are displayed using frame maps. It is necessary to distinguish between topographic and thematic content, with the majority (96%) being thematic charts. All thematic maps are related to health issues. The following overview maps of Tanzania give an impression of the Population Density and the Type of Medical Facility. The atlas ends with the methodology, explaining data aquisition, analysis and visualisation and the steps leading to the printed version of the atlas. The main focus of the atlas is placed on maps featuring data presented at the district levels. The data shows every medical facility and illustrates a detailed and small-scale inventory of healthcare services. All chosen topics are important in order to assess the quality of healthcare in every single facility. These aspects show the fundamental equipment to deliver basic healthcare in every facility. The themes of the maps in the atlas are in reference to:

4 622 J. Schweikart et al.. Type of facility (Dispensary, Health Centre, Hospital) and ownership,. Population and patient catchment area/staff relation,. Water supply,. Energy supply,. Garbage disposal,. Sterilisation methods of medical instruments,. HIV-Service-offers,. Accommodation offers for employees and. Reachability of the facilities. The themes of the maps were compiled within the framework of a workshop held in Mbeya City. Amongst the participants were members of the district health planning administration. The basis of the maps is founded on data capture at medical facilities that took place in 2008 and To collect those data, students, research assistants and professors of Beuth University interviewed the staff of all health facilities in the Mbeya Region. Additionally, GPS-data were collected in order to create a street network in detail in every district, and to locate facilities. All nine topics are spatialised in thematic fashion in each of the eight districts maps. Therefore, data can be compared across selected themes in the various districts. Each theme is spread over three double pages, whereby one legend is utilised per double sheet (see Figure 1). The scale of the maps ranges from 1:150,000 to 1:1,250,000, as each district varies in size and information density. One district is always depicted on the same scale. The topics are complimented by means of texts, pictures and diagrams. In the thematic maps of the Mbeya Region, the data for each of the eight districts have been summarised and visualised with the aid of diagrams. These illustrations rely on the district maps displaying the same topics. In Figure 1. Water supply in the Mbeya District, Mbeya City and Mbarali (main map).

5 Journal of Maps 623 addition, data from current statistics were analysed and visualised in a thematic map depicting the Top Five Diseases on a regional level of the Mbeya Region (Council Health Management Team, 2008). Before going into print, each map was presented in Mbeya and discussed with the employees in the health sector (first proof-reading). The central texts in the atlas, which include the introduction and the legends, have been written bilingually in English and Swahili to enable better understanding. This bilingual representation ensures that the contents are comprehensible and that the concepts of the maps have been customised to correspond with the competency and cultural needs of the users. After presenting and discussing the maps in Mbeya, all comments and suggested changes were included and proofed a second time before the atlas was printed. The analogue atlas is enhanced by a digital online version. 1 The complete atlas, as well as all maps and texts can be downloaded in PDF format. The maps are available separately or in combination with a legend. The first release will not include any interactive applications. An expansion of the atlas at a later stage, and also continuous, dynamic updates are being considered. 2.2 Workflow in Cartography The maps presented in the atlas go way beyond the information density and graphical structures of the working maps that are usually used in GIS. In order to upgrade the contents and cartographic presentation of the maps, graphic software was introduced. Thereby, each theme was individually visualised and cartographic information for communication was efficiently configured. Figure 2 shows the schematic depiction of the practical steps involved, starting from the data acquisition to the creation of the atlas. The working maps were exported from the Health-GIS via the software ESRI ArcGIS and subsequently processed with the graphic software Macromedia FreehandMX and Adobe Illustrator. The topographic contents were generalised and further supplemented with additional features. The actual state of the roads, before and after generalisation can be seen in Figure 3. The figure shows the identical map extract. Appropriate signage was placed in the maps for the all contents that are visually represented. In following steps, cartographic symbols were devised and positioned appropriately in each map. In the next stage, the map elements were accordingly labelled within the cartographic reference frame allowing for the correct allocation of information in a way that maximised legibility. During this process a number of cartographic problems occurred. The symbols are not distributed equally on the map, but rather appear more frequently along the roads and are in part particularly dense in the centres. The arising problem concerning the positioning of the symbols and the text is solved with the aid of indicator lines connecting the place names with the villages. If the space proved to be insufficient for neither symbol nor text, the health facility was localised with a dot and the combined information repositioned with the aid of an indicator line (see Figure 4). A digital elevation model (DEM) from publically accessible and freely available radar data of the Shuttle Radar Topography Mission (SRTM, srtm.csi.cgiar.org) was generated for the background of the maps. The DEM derived from the SRTM data, has an original resolution of approximately m. In scales larger than 1:300,000, the data shows steep and high slopes at numerous height intervals which are visualised in horizontal and vertical stripes. The digital elevation model is too detailed for scales smaller than 1:500,000 and creates a texture that is difficult to interpret on the digital hachure relief. In order to create an aesthetic three-dimensional digital representation, a generalised elevation model was calculated for the relief in each scale.

6 624 J. Schweikart et al. Figure 2. Database structure of the Health-GIS. Figure 3. Data before the generalisation (left) took place and afterwards (right). Finally, a shading function, imitating various lighting angles, was applied on these elevation models to finalise there representation in the maps. Afterwards all map components maps with legends, text, photos and additional information were put together in a uniform layout (see Figure 1). To ensure a high quality, a second proof-reading of the complete work was held in Tanzania before it went to print.

7 Journal of Maps 625 Figure 4. Assigning the symbol and the text. 2.3 Map Design The map design is based on the fundamental and formal components of a thematic map: Map frame, map face and map boarder (Figure 5). The map boarder is kept in a simple shade of grey so as not to distract from the contents of the map face itself. It contains the lettering which refers to the theme and the depicted region. The legend, scale and map face are situated within the map frame. Examples are attached in the legend, depending on the topic, to facilitate the interpretation of the symbols on the map by the reader. The map face contains a topographic relief (derived from the SRTM-Data), administrative boarders, street and path networks, identification tags of towns and villages and symbols used to visualise the topic. Each topic has additional images and elucidatory annotations demarcated in info-boxes placed on the map. The presentation of supplemental information is expected to allow the reader to gain a deepening insight into the map contents. The themes in the health atlas were implemented with the aid of standard cartographic map types: location maps, chart maps, choropleth maps and multi-layered maps. For the representation of qualitative data, a location map is suitable, wherein complex insignia and appropriate glyphs (symbols) provide the identifying information. The health facilities in the district maps were visualised by means of pictorial or symbolic emblems, based on the principle of association. The information hidden behind these symbols is presented in an exceedingly simplified manner and has a concrete bearing on the featured object (Hake et al., 2002; Olbrich et al., 2002). The featured arrays of symbols are understood by the readers and misinterpretation is reduced to a minimum. It is by way of example, typical to represent electricity depicting a descending zigzag arrow. In order to show the electricity supply of a health facility in the Health Atlas, this graphically abstract sign (see Figure 6a) was used, too. Through the use of colours the context of the symbols can be differentiated. A health facility that is powered by solar energy is tinted in orange. Facilities whose electricity supply is assured by their connection to the national power grid are inked in black. A combination of colours is applied to show several variables within one symbol. Therefore, a health facility that offers two out of four possible HIV-tests, received two different colour segments on the outer face of the symbol. This ensured that all available HIV-test options can be read off one symbol (see Figure 6b). In addition to the qualitative visualisation, quantitative methods were also utilised in the Health Atlas. Chart and choropleth maps were implemented. To reflect the number of employees working in a health facility, a circular chart divided into sectors was used to signify this statement. The diagram distinguishes between the employees who have been provided with housing for the

8 626 J. Schweikart et al. Figure 5. Example of the thematic map design. night and those where no overnight accommodation has been made available (see Figures 6c). Additionally to the circular chart, the method of bar charts was utilised in general maps of the Mbeya Region, in this particular instance, to show the five most common diseases per ward (smallest administrative unit in districts) (see Figures 6d).

9 Journal of Maps 627 Figure 6. (a) Commonly used symbol to visualise electricity (left), and the symbol used to show the electricity supply in the atlas (right); (b) Representation of four different HIV-testing options in one dispensary (facility for basic care); (c) Size shows the total number of employees in one health facility. The brown fill displays the number of employees who have overnight accommodation; (d) Representation of the five most common diseases found in one ward; (e) 5-km buffer zone around one dispensary. The dot represents the location of one village. Another representative form found in thematic maps is buffering zones. For this purpose Euclidean distance bands in equal intervals have been calculated and defined around each health facility. Buffers were chosen to represent the reachability of the health facilities. The time required or rather the distance to be travelled to reach a health facility can be determined by looking at the buffer zones. Thus it becomes clear which locations lie within a radius of 5 km and from which area a greater amount of time has to be calculated to reach the next health facility (see Figure 6e). 3. Conclusions Based on the data captured concerning health facilities between 2008 and 2009, the Beuth University of Applied Sciences in Berlin developed a Health Atlas in cooperation with the Ministry of Health in Tanzania, the GTZ and the TGPSH for the Mbeya Region in southwest Tanzania. This atlas depicts the most important aspects of medical infrastructure in the region and the most significant atlas maps show the healthcare services and the accessibility to health care facilities in all districts of the Mbeya Region. The Health-GIS project is pursuing several objectives. On the one hand it should help decision-makers who have no opportunity to use the GI-System for future planning or utilising spatial data in digital form. On the other hand, the production of the atlas serves as documentation for the actual state of affairs in 2010, which can be used as a basis for comparison in the future.

10 628 J. Schweikart et al. It was established that working maps could be expeditiously and effectively created using the Health-GIS. With these maps data are quickly displayed within a spatial context. However, the quality of the working maps still does not suffice to generate superior cartographic and reproducible master copies. During the process of developing the print atlas, it was obvious that it is necessary to edit the representations with graphic software. This pertains to all areas of cartography: the development of complex signage, generalisation of the maps and the labelling of objects. Transposition is clearly more effective using graphic software. The concept can also be applied to other regions. However, further steps are needed to reduce the costs of atlas development in order to optimise the processes and for automation to take place, especially for the compilation of the district maps. In order for the atlas to be used as an instrument in decision-making processes, it is necessary to implement standarisation on an institutional level. This has been achieved due to the involvement of the Tanzanian Ministry of Health in the production process whilst users in the Mbeya Region were tested for their comprehension of the symbols. Furthermore, proofreading of the atlas was done on a national level. More projects are planned in the future based on the Health-GIS and a publication is planned showing how the atlas can be used with the public health infrastructure being used as an example. In addition, a qualitative study is planned, to explore the planning impact of the atlas. Therefore, it is intended to evaluate the development of the inventory and equipment of the health facilities, and compare those data with the data from 2008/2009. Questions about increasing or decreasing the supply quality in the health facilities will be answered in future studies. Software The attributes and geometrical data collected on site have been entered into a geo database with the help of the Geographic Information System (GIS) ArcGIS Desktop version 9.3 from the company ESRI and have been processed. The core of ArcGIS is the component ArcMap that provides numerous tools for the spatial analysis of complex statistical data. Geometric data were visualised in ArcMap, enhanced with attribute data and evaluated. The results of the GIS-analysis were summarised in working sheet-maps and exported before being edited with the graphic software Macromedia Freehand and Adobe Illustrator. Both graphic design programmes possess numerous functions for visual and graphic processing of geo data which serves to produce printable cartographic products. Afterwards, the edited maps were put together to a printable atlas by using the software Adobe InDesign. Acknowledgements We would like to thank the project Applied Research in Health Programmes of German Development Cooperation, which is a sector of the German Society for International Cooperation (GIZ), for their financial support in the project and printing costs. Furthermore, we would like to extend our gratitude to the Tanzanian-German Programme to Support Health (TGPSH), in cooperation with the German Federal Ministry for Economic Cooperation and Development (BMZ), which financed the development of the pilot project Health-GIS in the Mbeya Region. A special thank you also goes to the Ministry of Lands & Human Settlements (MLHS) and the National Bureau of Statistics, Tanzania (NBS) for making the data freely available. In addition, a thank you to the numerous individuals who supported this project and could not be named here. Your contribution is much appreciated. Notes 1. Online Health Atlas: html

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