Primary care access and feasibility of Spatial Accessibility Index (SAI) in assessing primary care in rural Sri Lanka

Abstract

Despite decades of global health efforts and policies, inequitable access to primary care in low and middle-income countries remains an ongoing challenge. This study assessed accessibility to curative sector-primary healthcare services in the Anuradhapura district of Sri Lanka in 2020 and 2021. In this study, we included both private and state-owned primary care facilities (PCF) and their corresponding primary care doctors (PCD), covering both allopathic and complementary and alternative medicine (CAM) practices. Spatial locations of private sector PCF of the entire district were collected by conducting a comprehensive road-based survey and documenting information from publicly displayed boards. Data on state PCF were collected from provincial health departments (allopathic and Ayurveda). The Spatial Accessibility Index (SAI) of 657 GND (Grama Niladhari Division: the smallest administrative division) was calculated in ARC-GIS using the 2-Steps-Floating-Catchment-Area method in 5 km and 10 km spatial-distances from a GND. The majority of the PCF were allopathic (n=318, 78%) and belonged to the private sector (n=317, 79%) whereas CAM PCD represented one-fifth of the primary care workforce. Average SAI of 4.50X 10-4 and 4.67X 10-4 were reported for both 5 km and 10 km spatial-distance. A statistically significant difference in mean SAI was measured between urban and rural populations. The highest SAI were observed from urban populations and it gradually declined towards the rural remotes. The national primary care coverage target of 1 allopathic PCD per 5000 population was achieved only in 64% of the population in a 5 km spatial-distance and it further depleted to 25% with only of state allopathic PCD. SAI was negatively associated with the poverty headcount indices and distance to main roads and the main town (Anuradhapura). While the private allopathic sector is the main primary care provider in this study setting, a significant proportion of the population reported limited primary care access due to their geographic and economic status. Health policymakers need to address primary care workforce shortages in rural for the planning of human and physical resources. SAI can be recommended as a feasible method for healthcare planning and assessing service coverage in low-facility settings.