In China, upper-level healthcare (ULHC) and lower-level healthcare (LLHC) provide different public medical and health services. Only when these two levels of healthcare resources are distributed equally and synergistically can the public’s demands for healthcare be met fairly. Despite a number of previous studies having analysed the spatial distribution of healthcare and its determinants, few have evaluated the differences in spatial equity between ULHC and LLHC and investigated their institutional, geographical and socioeconomic influences and spillover effects. This study aims to bridge this gap by analysing panel data on the two levels of healthcare resources in 31 Chinese provinces covering the period 2003–2015 using Moran’s I models and dynamic spatial Durbin panel models (DSDMs). The results indicate that, over the study period, although both levels of healthcare resources improved considerably in all regions, spatial disparities were large. The spatio-temporal characteristics of ULHC and LLHC differed, although both levels were relatively low to the north-west of the Hu Huanyong Line. DSDM analysis revealed direct and indirect effects at both short-and long-term scales for both levels of healthcare resources. Meanwhile, the influencing factors had different impacts on the different levels of healthcare resources. In general, long-term effects were greater for ULHC and short-term effects were greater for LLHC. The spillover effects of ULHC were more significant than those of LLHC. More specifically, industrial structure, traffic accessibility, government expenditure and family healthcare expenditure were the main determinants of ULHC, while industrial structure, urbanisation, topography, traffic accessibility, government expenditure and family healthcare expenditure were the main determinants of LLHC. These findings have important implications for policymakers seeking to optimize the availability of the two levels of healthcare resources.

Background: Equity of healthcare spatial access is essential for the health outcomes of medical investments and the welfare of populations, and efficiency of medical resource allocation is important for obtaining a supply-demand equilibrium with lower cost and higher outputs with limited inputs. However, the literature that involves both equity and efficiency in its analysis of healthcare spatial allocation is rare, and the spatial accessibility of multilevel healthcare is difficult to measure by traditional methods in a large region with diversified population distribution. Methods: To assist in solving these issues, this paper aims to build an equity and efficiency integrated analytical framework by proposing a new “GTL-2SFCA” approach to analyze the spatial accessibility of multilevel healthcare; maximum and minimum floating catchments of different levels of healthcare were assigned to ensure a combination of universal search coverage and efficient hospitalization behavior simulation. Results: The analytical framework was applied and tested in Hubei, China. Almost half of the residents (47.95%) and townships (44.98%) have access to both public general hospitals (PGHs) and primary healthcare centers (PHCs) services, 36.89% of the residents enjoy only one sufficient service, either PGHs or PHCs, and the remaining residents (15.16%) are faced with the risk of lacking access to both services. The results reveal that there are core-periphery effects of multilevel healthcare throughout Hubei and isolate clusters that have adequate access in the western region. The polarization effect of higher-level healthcare and the polycentric pattern of lower-level healthcare coexist. The multilevel healthcare shortage was identified in some areas in boundary and peripheral regions. Conclusions: This study integrates equity and efficiency into the GTL-2SFCA framework, enriches the FCA series methodologies and provides a more operational solution for evaluating the access of residents in more sophisticated spatial units to each level of healthcare. By more significantly differing and quantifying the catchment area and distance decay effect, this methodology avoids overestimating or underestimating accessibility and discovers some imperceptible spatial inequities. This study has application value for researchers and decision-makers in other scenarios and regions with significant heterogeneity in medical resources and where the population has greater mobility.

The spatial equity of the healthcare system is an important factor in assessing how the different medical service demands of residents are met by different levels of medical institutions. However, previous studies have not paid sufficient attention to multilevel healthcare accessibility based on both the divergence of hierarchical healthcare supplies and variations in residents’ behavioral preferences for different types of healthcare. This study aims to propose a demand-driven “2R grid-to-level” (2R-GTL) method of analyzing the spatial equity in access to a multilevel healthcare system in Chengdu. Gridded populations, real-time travel distances and residents’ spatial behavioral preferences were used to generate a dynamic and accurate healthcare accessibility assessment. The results indicate that significant differences exist in the spatial accessibility to different levels of healthcare. Approximately 90% of the total population living in 57% of the total area in the city can access all three levels of healthcare within an acceptable travel distance, whereas multilevel healthcare shortage zones cover 42% of the total area and 12% of the population. A lack of primary healthcare is the most serious problem in these healthcare shortage zones. These results support the systematic monitoring of multilevel healthcare accessibility by decision-makers. The method proposed in this research could be improved by introducing nonspatial factors, private healthcare providers and other cultural contexts and time periods.

Residents of rural areas live and depend on the land; hence, rural land plays a central role in the human–land relationship. The environment has the greatest direct impact on farmers’ lives and productivity. In recent years, the Chinese government carried out vigorous rural construction under a socialist framework and implemented a rural revitalization strategy. This study was performed in a rural area of Huanjiang County, Guangxi Province, China. We designed a survey to measure rural households’ perceptions of three types of rural spaces: ecological, living, and production spaces. The survey was administered to 379 farmers, and their perceptions and satisfaction with Ecological–Living–Productive spaces were evaluated with the use of structural equation modeling. Analysis of latent and observed variables indicates that: (1) Farmers’ overall satisfaction with Ecological–Living–Productive spaces was moderate. The average satisfaction score for production spaces was lowest (2.881) while that for living spaces was highest (3.468) and that for ecological spaces was in between (3.351). (2) The three most important exogenous observed variables associated with living space satisfaction were house comfort > domestic water supply > domestic sewage treatment. The three most important exogenous observed variables associated with production space satisfaction were irrigation water > cultivated land quantity > cultivated land fertility. The three most important exogenous observed variables associated with ecological space satisfaction were garbage disposal > vegetation cover > flood and waterlogging. Based on the requirements of the rural revitalization strategy and the results of our analyses of rural households’ spatial perceptions, we propose corresponding countermeasures and suggestions.