Presentation on About Geography of Health: Reflections on Concepts & Relevant Techniques by Dr. Smita Gandhi during Seminar on Spatial Dimensions on Health Care - Use of GIS in Health Studies Organised by CEHAT and University of Mumbai on 24th Sep 2010

1. A National Seminar on
Spatial Dimensions on Health Care-
Use of GIS in Health Studies
Centre for Enquiry into Health and Allied Themes
(CEHAT)
Vakola, Santa Cruz (East), Mumbai- 400055
and
Department of Geography,
University of Mumbai, Vidyanagari, Kalina, Mumbai 400 098
24 September 2010

2. About Geography of Health:
Reflections on Concepts and Relevant
Techniques
Smita Gandhi,
Department of Geography,
University of Mumbai

3. Introduction
 Whereas Survival is a basic instinct of living beings, Concept of Health and
Health Care is essentially a manifestation of human culture.
 Struggle for life, therefore, is conditioned by “good” or “bad” health and is
intricately linked with insights into human body as space on one hand
and the situated spaces of human body, its senses and cognition on
the other.
 Being healthy and seeking/organising Health Care is thus utmost place
space specific and vary quite dramatically across space and time.
 It is in this context discourse on Health and Health Care is conditioned by
the spatiality of Society, Economy and Environment.

4. Knowledge Base on Health and Health Care:
Transcending Beyond the Regime of Bio-medical
Sciences
 With the development of medical science in the post industrial revolution
period, the focus of the knowledge base shifted from considering health as
a product of an individual’s essential character to that of the bacterial agent
as interpreted by the Germ theory.
 This shift rendered human body to be the object of the institutionalized
gaze of the medical practitioners (Foucault, 1976: 59).
 Yet the etiological interpretations of disease, health and health care
systems could extend cutting across the boundaries of the natural and
especially bio-medical sciences and permeate into the realms of social
sciences, since the mid 19th century, which paved way for geographical
discourses on diseases and health.

5. Evolution of Approaches to Geography of
Health
 Discourses on Geography of Health have evolved coinciding with various
phases of paradigm shifts in Human Geography, which have led to
emergence of ecological approach in the form of conventional Medical
Geography in the mid 20th century.
 In the initial stage, Geographers involved in unfolding various
interrelationships between man and natural environment as their core
concept, strengthened the ecological approach to health. Thereby, they
contributed to the emergence of the sub-field like Medical Geography.
 Remaining within the confines of the idiographic traditions, in its inception
this branch narrowly focused on environmental contextuality through
descriptions of distribution of diseases and sought interrelations of causes
of morbidity and conditions of mortality varying across space.
 By 1950s however this field adopted the philosophy of Positivism and the
conceptual bases of spatial analysis.

6. Evolution of Approaches to Geography of Health
Gende Age
r
The interpretations drew upon
coincidence in time and space
Genetic
of agent, host and s
environment (May, 1950). Population
Medical Geography thus
facilitated replacement of Germ Habitat Behaviour
Natural Beliefs
theory by multifactorial disease
causation theory and the
epidemiological triangle
Built Social Technolo
Social
focused on interrelations Organisatio y
n
between Population, Habitat and
Behaviour as the basic elements
Medical Geography and
and through which extending to
The Triangle of Human Ecology
the specificities of their ( Meade and Erickson , 2000:25)
individual dimensions such as
gender, age and genetics as
illustrated in case of population.

7. Typology of Research Themes in Medical Geography
Researches in Medical
Geography can be broadly
classified under four major themes
(Dev,1991:10):
I.Disease Mapping or Mapping of Ill
Health
II.Environmental Health Hazards
and Ecological Associative Analysis
related to: Disease Ecology,
Cultural Ecology , Diet Nutrition,etc.
III.Disease Diffusion Studies
Relating to Specific Diseases and
their Spread over Space and Time
and
IV.The Geography of Health Care
Studies based on descriptive,
inferential and synthesising
cartographic and quantitative
techniques and models have been
effectively employed by the
geographers to analyse the paths
of epidemics and pandemics (Dey,
2004:118) that have enriched this
subfield and offered an insight into Types of Research Theme and Spatial Scale of their
various medical phenomena. Universe
( Thomas, M. 1988:15)

8. Relevance of Welfare Human Geography Approach
in Health care Studies
 With the emergence of Welfare Human Geography School as an explicit critique of
the positivist traditions, Geographical inquiry became increasingly multifaceted
and socially relevant (Gandhi, 2007:394-402).
 The word 'welfare’ sometimes defines social security, at times it may also define
a set of social policy measures. A distinction is commonly made between
economic and general social welfare, the former denoting the consumption of
goods and services in lieu of money and the resultant satisfaction, while the latter
embraces all items contributing to the quality of human existence (Smith, 1973).
 Although a crucial requirement of any social service is its viable location in the
right place where people need it, it has been consistently found that either a
distance- decay effect or an ‘inverse-care law’ exists in their locational dimension.
This mismatch induced geographers’ interest in 1970s to study the price of
accessibility and costs of proximity to these services and ultimately answer the
seminal question of the Welfare Human Geography, ‘who gets what, where and
how ?” (Dev, 1991:30)
 Among these pertinent questions, who denotes individuals or social groups, what
relates to goods and services and aspects of wellbeing while where indicates
locales and territorial distribution. The last and most crucial of these questions, ‘how’
relates to the underlying fabric of social organization and the economy , its goals and
value systems. All these relate to the criteria and strategies of redistribution of goods
and services.
 Significant query therefore is whether these services are spatially and socially
concentrated or diffused and dispersed? This last question therefore probes into

9. Development of Geography of Health
in the Arena of Social Geography
 The underlying thrust of the Welfare in Human Geography thus lies on the
interdependence of the spatial organization and the structure of the social,
economic and political sub-systems in society with respect to fulfillment of needs
of all the segments of society as organized in place and space so as to ensure social
welfare and quality of living.
 Harvey’s (1973) arguments on spatial and territorial justice become very crucial in
this context. His emphasis on making the deprived state of existence and spatially
variable condition of welfare of millions of people in the real world as the focal theme
of geographical studies provided a great impetus to the research on quality of living
that was set to examine and explain territorial index of well being. Studies on Health
and health care became one of the major thrust areas of such research.
 Subsequently, sub-fields like Geography of Health emerged as off-shoots of
Social Geography and adopted newer qualitative and critical approaches,
though social geographers of health care also used the spatial models to examine the
distribution of medical services (Earickson, 1970; Misra 1970; Shannon and Dever
1974; Shannon and Spurlock 1976; Pyle 1977; Phillips, 1981).
 The humanistic turn to the research in this field interpreted health and illness as
the socio-cultural constructs with an emphasis on ethnographic approaches and
explicit qualitative methodology.

10. Social Geography's Methodological Approaches :
Theories of Space- I Spatial Scientific II Humanistic

11. Social Geography's Methodological Approaches :
III Radical IV Poststructural

12. Conceptualising Spatiality:
Dialectical Relation between
Social and Spatial Structures
The churning in Geographical thoughts
persisted in the 1980s and post-1990s as
well, contributing to the emergence of
Radical and Critical Geography
perspectives.
Patterns of healthiness and the associated
therapeutic spaces are now conceived to
be structured by the interrelationship
between socio-spatial structures that are
the product of historical processes
operating in the resultant socio-cultural
and politico-economic framework.
These structures mediate and at times
regulate, how people gain access to the
needed resources related to their bodily
as well as mental and emotional health
(Casino, Jr., 2009: 99).
 These shifts have not only fused the
Geography of Health Care with the spatial
interpretations of Social Well Being and
Quality of Life but have also facilitated
inclusion of
in ensuring territorial and social justice in
the provision of health care.

13. Geography of Health Care:
Illustrative Case Studies
 In the context of these conceptual developments in the arena
of Geography of Health, present study draws upon and
collates the findings of some relevant case studies on Health
Care from Maharashtra.
 These researches unveil spatio-social imbalances in
distribution of health facilities.
 Analysis of their accessibility conditions reflect on gaps in
territorial justice and quality of life status as observed within a
city and between city and city region.
 The first case study analyses the spatiality of Drugstore as an
auxiliary healh function in Pune City, in 1981 (Joshi/Gandhi,
1985)

14. Delineating Spatio-Social Levels of Accessibility to Drugstore,
An Auxiliary Health Function in Pune :
A Second Ranking Third World Metropolitan City
 This case study draws from a research ‘On The Spatial Pattern of Drug-retailing in
Pune City’ in the early eighties (Joshi/Gandhi, 1984,1986) in the framework of Urban
Economy and Geography of Marketing, a sub-field of Economic Geography.
 This study illustrates how the spatiality of a health care input like a drugstore is essentially
produced by the economics of effective demand rather than need based demand.
 Range for a drug store is defined in terms of distance covered by walking in five, fifteen
and thirty minutes1. Thus, the map area of Pune city showing the distribution of
drugstores in 1980 has been covered by a suitable grid network and each point of
intersection of the grid is assumed to be the probable point of consumption of drugs and
medicines.
 Considering each of these points as a centre, circles with radius equal to five minutes
walking distance in city and fifteen minutes in the periphery have been drawn. The number
of drugstores circumscribed by each circle in this manner is counted and thus, the
drugstore accessibility score is then assigned to each of the grid intersections conceived as
the consumption points. Choosing appropriate interval, the isolines delineating conditions
of accessibility to drugstores have been constructed.
 This study analyses the observed spatial pattern of drug-retailing in Pune City in
1980-81 by perceiving a drug-store as a need-based function auxiliary to health
care, which, therefore, is expected to be located in close proximity to the place of
residence.
 Using quantitative and cartographic techniques like regression residual and isoline
mapping based on time distance, this study delineates differentiated patterns of
accessibility to drugstores in Pune city.

15. Factors Influencing Spatiality of Drugstores
Volume of Traffic and Location of
Concentration in Relation to Population Drugstores

16. Threshold and centrality
The following observations can be made :
Conditions of Drugstores in
(i) In general, threshold requirements for drug-retailing terms of Dispensaries and
increase with increasing distance from the core and doctors
declining centrality conditions. However, factors such as
variations in the conditions of accessibility and flow of potential
customers, socio-economic composition of residential areas,
occurrence of the initial retail nucleus, etc., explain the
anomalies.
(ii) The spatial pattern of drug-retailing has been better explained
by the demand variables establishing the functional
interdependence (doctors and dispensaries).
(iii) The areas in the inner core characterise the traditionally
developed retail and commercial core of the city and its role has
been further strengthened and intensified as the city has
undergone industrial and urban development.
(iv) Inner periphery promises enough conducive
environment to develop as a secondary retail nucleus as the
residential areas have tended to disperse away from the city.
(v) Both the core and the periphery reflect varying levels of retail
and urban development and outermost core and outer periphery
reflect similar threshold conditions.
(vj) Outer peripheral areas reflect varying characteristics.
Occurrence of slums, industrial workers colonies,
commercialisation of agriculture in the hinterland of the city
as well as well developed accessibility conditions together
have led to the development of retail facilities in some of the
units, while some other have experienced a time-lag in the
initiation of the same.
(VK) In spite of the absolute growth in the number of
establishments and the subsequent decline in the threshold
requirements, the spatial pattern of drug-retailing and variations
in the threshold conditions confirm the fact that drug-retailing is
still a semi-specialised retail function.

17. Conceiving Accessibility from Supply Side:
1. The above analysis focusing on the demand
component of a drugstore has been also The patterns of intense, moderate
complemented by introducing the dimension and low overlap of the service areas
of supply within the same framework of five, have been distinguished and also the
fifteen and thirty minutes walking distance. areas remaining un-served have
2. Taking the location of each drugstore as been demarcated (Fig.1).
centre, circles with the given radius have been
drawn to delimit the market areas of the given
outlet.

18. Spatio-Social Accessibility to Drug retailing
in Pune City in 1981
 The isoline map is drawn to
attempt regionalisation defined
by need base consideration of
a) 5 minutes walking distance
from point of consumption in the
core area of the city of Pune
b) And 15 minutes in the
extended areas including the
periphery of the city.
 The isoline map delineates the
areas of high, medium and low
accessibility, which in turn
indicate areas of varying degree
of concentration of drugstores in
contrast to those having dearth
of the same.

19. Projecting Spatio-Social Inaccessibility to
Drugstores in Pune: A Synthesis
 A Synthesised pattern of accessibility to
drugstores is obtained by delineation of zero or
no accessibility to drugstores within the given
limit of 15 minutes walking distance.
 This pattern highlights zero accessibility
areas as also the potential areas for locating
drugstores in Pune.
These findings simultaneously expose gaps in
spatial and social accessibility to the ancillary
function of health care in Pune City.
Thereby these also provide an objective
measure of the welfare content in urban
planning as implemented in the second ranking
metropolis like Pune in 1980s.
In case of Pune city this need base analysis of
accessibility to drugstores has not only been
helpful in demarcating the outer peripheral
parts of the city that experience poor
accessibility conditions
but it has simultaneously revealed the areas
of relative inaccessibility to drug retailing in the
core areas of the city which coincide with the
residential areas of low class as well as caste
status.

20. Accessibility to Private Hospitals in Mumbai, 1980s
(with >than 50 Beds)
Demand based: 45 minutes Walking Distance Supply Based: 30 Minutes walking distance
from point of consumption: the residence circumference
( By Thomas M., 1986)

21. HEALTH FACILITIES IN PUNE
 This case study examines Distribution of Health Facilities in Pune in 1980s. It study
deals with the spatial distribution of health facilities in Pune district and attempts to
bring out the disparity in the distribution at two levels (Joshi/Gandhi and Banerjee,
1986 ),
(i) in Pune metropolitan region and the remaining talukas of Pune district and
(ii) in Pune city and the other settlements within Pune metropolitan region.
The former brings out the disparity at a wider regional level, while the latter reveals
the inter-urban disparity and the supremacy of the metropolitan core.
 Ten indicators have been selected to denote health care facilities, namely :
(i) number of family planning centres, (ii) number of primary health units,
(iii) number of dispensaries, (iv) number of drug stores,
(v) number of doctors, (vi) number of beds in hospitals,
(vii) number of minor community hospitals,
(viii) number of major (specialized) hospitals and nursing homes,
(ix) number of hospitals with teaching facility and
(x) expenditure on health and sanitation facilities by village panchayats,
municipalities, cantonment boards and corporation for respective settlements.
 Data on 'the above indicators have been computed for Pune metropolitan region
including Haveli taluka and the remaining talukas of the district.
 From percentage share of these talukas for each indicator the mean percentage
share has been calculated and analysis accordingly done.

22. Urban Rural Disparity in Access to
Health Facilities in Pune

23. Dominance of Metropolitan Region in
Distribution of Health Facilities
Mean % of Health Facilities in Primacy of Health Facilities in
Pune Metropolitan Region (PMR), PMR
1980
Sr. Unit Percentag
No. e
1 Pune City 79.0
2 Pune 11.0
3 Cantonment
Kirkee 02.0
4 Dehugaon 00.14
5 Pimpri Chinchvad 05.0
6 Dehu Road 0.71
cantonment
7 Khadakvasla 0.85
Urban Total 97.0
Rural Total 03.0 Dispensaries, Doctors and Minor Hospitals are
the only few functions that have marginally
penetrated beyond PMR

24. Explaining Socio-Spatial Inequality to Health Facilities
in Pune District
 The disparity attains greater magnitude in Pune City, the PMR and District as one takes into
consideration the range of facilities.
 Like any other commercial or retail function, spatial organization of health facilities and their range
also seem to be affected by the correlated factors of physiographic constraints, land use pattern,
development of agriculture, nature, type and location of industrial units and various demographic
characteristics. A cumulative effect of positive or negative interaction of these factors has contributed
toward a spatial pattern of effective demand; and the distribution of health facilities responds to this
effective demand neglecting the needs of the people.
 A dominance of the metropolitan region with Pune city as the core is evident, having facility counts
ranging from 800 to more than 1600.
 (ii) Commercialization of agriculture in the northern and northwestern parts of Pune district has
resulted in a consequent size of effective demand and purchasing power. This has occurred due to
the expansion of the hinterland of Bombay and Pune markets as well as the growth of agro-based
industry, especially, sugar mills. In Baramati taluka, 29 per cent of the total settlement with 57 per
cent of the total population enjoys some sort of health facility having counts between 300 and 400.
However, one-third among these represents urban centres accounting for 60 per cent of the total
count.
 (iii) The inaccessible hilly areas of the western talukas like Velhe, Mulshi and
Bhor with total number of settlements ranging between 130 and 185, face a dearth
of facilities. Only less than 10 per cent of the settlements in these talukas has
direct access to some facilities. ,

25. Core-periphery hiatus and Rural-urban bias
 (iv) Along with core-periphery hiatus, a -rural-urban bias is also distinct. In the
southern, southeastern and northwestern talukas like Purandar, Bhor, Daund and
Maval the few urban centres controlling the economy of the taluka account for more
than 50 per cent of the total count. In Maval talukas out of 38 per cent of the total
population having direct access to a health facility, 31 per cent is urban.
 (v) In the rural areas health facilities are located in the bigger villages and/or trade
centres located along the major transportation routes. This is observed in the
northern talukas of Khed, Ambegaon, Junnar and Sirur. Settlements having some
sort of health facility are often weekly markets with a population of 1000 and a
proximity to bus routes. health facilities at a micro-level.
 In Pune, the pattern of disparity in the distribu-tion of health care is well pronounced.
In the metropolitan region, Pune city has a share of 79 per cent of total facilities,
while in the district Pune metropolitan region enjoys 89 per cent of the total.
 It is thus evident that in the process of allocation of these facilities much
debate still awaits between the need-based and demand-based policies.

26. Healh Care Provision Reveals Trends of
Market Based Cumulative Growth Trends
 In less developed countries the spatial distribution of health care
services and the modern health facilities still continues to remain
highly centralized.
 Riddell (1970) states that this pattern owes its origin to the old
colonial administration whose attention was focused on the provision
of medical services for government personnel and administrative
centres.
 Subsequently, under independent government also the locational
policies go to choose the already developed economic centres.
This delays the process of equitable distri-bution of facilities.
 In combination with this process, Harvey (1973) argues, the more
affluent in the present society organize themselves through the
political system to maximize their real income, thus leading to
considerable inequality in resource allocation.
 The above case studies corroborate these observations and
emphasise that
in the process of allocation of these facilities much debate still awaits
between the need-based and demand-based policies.

27. The Context of the Reciprocal Relationship Application of GIS in Health Studies: GIS is
between the Three Elements that Shape and Primarily Capable of Analysing various
Aspects of the Absolute Space. That Leaves
Reshape Human Landscapes : out the Entire Gamut and Complexities of
Related to Health and Wellbeing Relative Space, to be Explained by the
Theoretical Understanding about the
The conceptualisation of thereaupatic spaces and Interrelationship of Spatial and Social. That
those of Health and Health Care is necessarily warrants Researches in Health Studies to
embeded in the reciprocal relationship between Transcend Beyond the Technical
relatively long- term structural forces and short Complementarities Offered by GIS
term routine practices of individual agents, as
mediated by the institutional forms

28. Ilustrating Role of the Institutions
Apathy of the State and the Private Sector in
Controlling Chronic Trends of Epidemics:
Where is the Integrated Policy of Health,
Global Concern regarding Housing and Employment to ensure Social
Chronic Diseases! Well-Being

29. Appropriation of Resources by the Corporate Sector and
Exclusion of the Poor from Health Care under PPP
PIL Filed at New Delhi High Court as Private
Case of Andheri’s Seven Hills: The Hospitals Deny Free Access to Hospital
Corporate Hospital in Mumbai Beds To the Poor and Flout the Rules

30. What is the Role of the State in
Organising Health Care?
So many Invitations to the Researches on
Health and Health Care
That need to integrate
Social and Spatial
With or without GIS Applications is
Merely a Methodological Choice