The overarching aim of this study is to develop a GIS-based planning approach that contributes to equitable and efficient provision of urban health services in cities in sub-Saharan Africa. Its prime concern is with (i) the identification of theoretical and methodological constructs that can be used to analyse and improve the spatial performance of public health service delivery systems, and (ii) the development of a corresponding spatial-analytic and GIS-based planning approach using Dar es Salaam as a case study. The broader context of the study is the 'urban health crisis'; a term that refers to the disparity between the increasing need for medical care in urban areas against the declining carrying capacity of existing public health systems. The guiding principles of the primary health care approach (equity, effectiveness and efficiency) form the point of departure of the research. They demonstrate that health care provision is inevitably tied up with issues of resource allocation, distribution and priority setting. Decisions have to be made about the nature and range of services to provide and how they are distributed amongst the members of society. Such decisions are informed by economic, political, medical and ethical considerations but - as this research underlines - should also consider the spatial dimension. To evaluate alternative spatial distributions in equity and efficiency terms and suggest improvements, spatial performance indicators are required. Such indicators are generated via the accessibility concept which is seen as a notion with a socio-economic as well as a spatial dimension between which important interactions exist. The analysis culminates in a 'what if' type of planning approach designed to evaluate and improve the spatial performance of the Dar es Salaam governmental health care system. In doing so it illustrates how more sophisticated GIS-based analytical techniques can be usefully applied in support of strategic spatial planning of urban health services delivery. It consists of an evaluation and an intervention framework. The evaluation framework appraises the performance of the existing Dar es Salaam governmental health delivery system on the basis of generic quantitative accessibility indicators. The intervention framework explores how existing health needs can better be served by proposing alternative spatial arrangements of provision using scarce health resources. It consists of a set of 'what if' type of planning instruments that can support health planners to (i) detect spatial deficiencies of a given delivery system, (ii) propose priority spatial planning interventions and (iii) estimate the expected impact of potential interventions on spatial performance. When used in concert the developed planning instruments offer a flexible framework with which health planners can formulate and evaluate alternative intervention scenarios and deal with the most important problems involved in the spatial planning of urban health services. The planning instruments, finally, are designed to contribute to making informed spatial decisions; not to automate but rather to support part of the planning process.
