Co-evolution of private and public hospitals: spatiotemporal disparities, geospatial interactions, and social determinants over 19 years in Sichuan, China

Xiao Liu¹Xiuli Wang¹Yaqian He²Jinghua Wang¹Xiange An¹Lingfeng Liao¹Xiang Yan³Yumeng Zhang¹Chao Song^1*Jay Pan¹

• ¹HEOA–West China Health & Medical Geography Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
• ²Department of Geosciences, University of Arkansas, Fayetteville, United States
• ³College of Architecture and Environment, Institute of Urbanization Strategy and Architecture Research, Sichuan University, Chengdu, China

Background: The global rise of private hospitals is crucial for achieving universal health coverage, yet the development of public and private hospitals remains uncoordinated. This study explores the co-evolution of private and public hospitals, focusing on their spatiotemporal disparities, geospatial interactions, and the social determinants under policy guidance. Methods: We used Sichuan province, China, as a case study and collected hospital-level annual report data from 2002 to 2020. Spatiotemporal analyses examined the co-evolution of public and private hospitals across different hierarchical levels. The Gini coefficient assessed the spatial equity of hospital bed resources, while spatial accessibility was measured using the provider-to-population ratio at district and county levels. Trend analysis quantified changes in accessibility over time. Fixed-effects models identified social determinants influencing hospital resource allocation. Results: Between 2002 and 2020, the proportion of districts/counties in Sichuan with more than 4.8 hospital beds per 1,000 population increased significantly, from 5.46% to 43.72%. The equity of medical bed resources also improved across the province. The proportion of districts/counties with more than 3.3 public hospital beds per 1,000 population rose from 12.57% to 50.27%, and the share of districts/counties where private hospitals made up 25% or more of total beds grew from 2.19% to 53.01%. Geospatial interaction maps revealed regional disparities: complementarity in advantaged areas, persistent deficits in remote regions, and geographical compression of public hospitals in urban centers. Our analysis further showed that private hospital accessibility positively correlates with population density, per capita GDP, and government health expenditure, while public hospital accessibility is positively linked to per capita GDP, urbanization, and health expenditure. However, public primary hospital accessibility negatively correlates with per capita GDP. Discussion: While private hospitals have rapidly expanded bed capacity, policy biases and market incentives have caused a structural imbalance, with a shortage of high-end services and an excess of low-end resources. In contrast, public hospitals have upgraded hierarchically, concentrating high-quality resources in urban areas. However, basic medical supply remains insufficient in remote regions, exacerbating disparities in healthcare accessibility and quality, and hindering the achievement of universal health coverage.