Examining healthcare inequality for non-communicable diseases in Malawi: a hierarchical geospatial modelling approach.

Abstract

The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries, including Malawi, yet spatial inequalities in NCD healthcare coverage remain poorly understood. In this research, we aim to: (1) develop a novel hierarchical geospatial framework to assess population coverage and accessibility of NCD services in Malawi and (2) identify underserved areas and provide evidence for targeted resource allocation. Using 2019 Malawi Harmonized Health Facility Assessment Survey, hierarchical catchment areas were defined by facility type-primary healthcare (PHCs), district-level and central hospitals, with distance thresholds of 5 km walking, 25 km driving and 100 km driving, respectively. Incorporating facility readiness, we computed population coverage at the third administrative level. When estimating spatial accessibility, we used enhanced two-step floating catchment area, applying Gaussian distance decay for chronic conditions and inverse power for acute conditions. Secondary and tertiary facilities (STFs) covered over 60% of population, providing broader NCD service than PHCs, where coverage was lower than 20%, particularly for acute conditions. Population coverage was higher in central and southeastern Malawi, notably around Mzuzu, Lilongwe and Blantyre. However, at least 24% of the population were not covered for any NCD conditions. Additionally, only 11.9% of the population lived in regions of high or very high accessibility to PHCs. We found substantial geographic inequalities in NCD service coverage and access, highlighting underserved regions and the demand to strengthen PHC readiness. This hierarchical geospatial approach offers insights for resource allocation and improving healthcare equity in other low-resource settings.