Evaluating health service equity at a primary care clinic in Chilimarca, Bolivia

Policy makers and health planners generally support the concept of equitable health care. A focus on who can use a health service, or its potential access, will not necessarily lead to equitable care if people are not willing to avail themselves of the health services offered. Because equity is difficult to operationalize, outcome-based indicators such as the actual utilization of services are advocated as a means to measure equal access. This paper evaluates the utility of linking the concept of equity with a temporal and spatial analysis of clinic users at a micro scale, supplemented by a community survey. Various spatial scales were employed in the analysis. Utilization of the primary care clinic in Chilimarca, Bolivia varied considerably during the first 25 months of operation. Spatially, utilization shifted away from the targeted service area. Within the targeted service area, usage was concentrated in a few blocks of the community and generally diminished with increasing distance from the clinic. The survey further revealed place of origin, length of residence, and language spoken at home as variables differentiating users from non-users. Failure to include the spatial dimension of utilization would lead to different conclusions if only aggregate data were employed. Spatial analysis of output measures is imperfect and does not necessarily deal with all of the access issues related to acceptability. They do, however, begin to isolate areas of a defined geographic area where further investigation would assist in ascertaining, and subsequently addressing, potential problems related to equal access.