Social Science & Medicine 58 (2004) 2045–2067 Changing geographic access to and locational efficiency of health services in two Indian districts between 1981 and 1996 Naresh Kumar Population Studies and Training Center, Brown University, Box 1836, Providence RI 02912, USA Abstract In developing countries, including India, the role of the private sector in the provision of basic healthcare services is gradually expanding, since the public sector provides limited services and covers only limited areas. Using location- allocation models (LAM), this paper (1) examines the changing geographic access to and locational efficiency of basic public healthcare vis- " a-vis private healthcare services in two districts located in northwestern part of India, and (2) interrogates the factors that govern their geographic accessibility and locational-efficiency. Although this research confirms regional inequalities in geographic accessibility and locational efficiency of both public and private healthcare services in the selected districts, the locational efficiency of private health services is significantly lower than that of public health services. This paper further demonstrates the use of LAM for new site identification (keeping the existing healthcare sites intact) that will, in the future, improve locational efficiency of these services. This paper not only recommends improved geographic access to both public and private health services and their enhanced complementary role, but also stresses the need to evaluate geographic access from the service-users’ perspective and the use of more realistic data on demand and supply in future research. The findings of this paper can be extended to areas with similar geographic settings, and socio-economic and demographic conditions. r 2003 Elsevier Ltd. All rights reserved. Keywords: Health services; Geographic accessibility; Locational-efficiency; Location-allocation model; locational simulation; India Introduction After the Second World War, most developing countries, including India, started investing in the provision of public health service as a part of their development plans, since public health was directly linked to human well-being and overall social and economic development (Knowles, 1980; McEvers, 1980; Phillips, 1990; Sen, 1996; World Bank, 1980, 1994). As a result of this, India experienced a dramatic decline in the death rate and an increase in the life expectancy (Census of India, 1997). However, even with these achievements, morbidity rates have remained persistently high, because a major section of the population, especially in rural and less developed areas, lacks adequate access to curative health services (Kumar, 1999). Access to healthcare services includes many geo- graphic, economic, cultural and political factors. Among these, geographic access (generally measured in terms of traveling cost) is the most significant factor in the utilization of health services. Although the number of healthcare services in India has increased substantially since the beginning of the first Five Year Plan in 1952, urban and developed areas enjoy better geographic access to healthcare services (both public and private) as compared to rural and less-developed areas (Govern- ment of India, 1997). Recent literature shows that political interventions and economic forces (Kumar, 1999; Rahman & Smith, 2000), and also government policies (Rushton, 1988) skew the distribution of healthcare services in favor of developed and urban areas. In order to overcome this problem, a number of studies recommend the use of objective measures, including location-allocation models (LAM), for planning new health service locations so that their ARTICLE IN PRESS E-mail address: naresh kumar@brown.edu (N. Kumar). URL: http://nk.gis.brown.edu. 0277-9536/$-see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2003.08.019