Use of Spatial Analysis to Assess Geographic Accessibility of Community Pharmacies in São Mateus

doi:10.4236/pp.2013.45062

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Pharmacology & Pharmacy, 2013, 4, 438-442

http://dx.doi.org/10.4236/pp.2013.45062 Published Online August 2013 (http://www.scirp.org/journal/pp)

Use of Spatial Analysis to Assess Geographic Accessibility

of Community Pharmacies in São Mateus

Brígida Dias Fernandes1, Aracelli Ferreira Lírio1, Rodrigo Randow de Freitas2*,

Ana Carolina Melchiors3

1Universidade Federal do Espírito Santo-UFES, Centro Universitário Norte do Espírito Santo-CEUNES, Departamento de Ciências

da Saúde-DCS, São Mateus, Brasil; 2Universidade Federal do Espírito Santo-UFES, Centro Universitário Norte do Espírito

Santo-CEUNES, Departamento de Engenharias e Computação-DETEC, Núcleo de Pesquisa em Gestão de Sistemas de Produção

(NPGSP), Laboratório de Gestão Costeira-Aquicultura e Pesca (LGCap), São Mateus, Brasil; 3Pharmacy Pratice Research Group,

Departamento de Ciências da Saúde-DCS, São Mateus, Brasil.

Email: *[email protected]

Received May 20th, 2013; revised June 28th, 2013; accepted July 19th, 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Pharmaceutical services contribute to the rational use of medicines by ensuring the provision of appropriate, safe and

effective pharmacotherapies. Thus, it is important to investigate whether the geographical distribution of pharmacies

causes inequalities in access in countries like Brazil, where there is no federal law regulating the opening of new esta-

blishments (in contrast to many European countries). This study analyzed the accessibility of community pharmacies in

the city of São Mateus, Espírito Santo, Brazil. The authors obtained the geographical coordinates of pharmacies and

healthfacilities, which scanned and georeferenced the study area. The 40 pharmacies included in the spatial analysis

presented a heterogeneous distribution, with the existence of neighborhoods with an accumulation of pharmacies and

others with no pharmacies. The authors found that only 43.7% of the study area received pharmaceutical service covera-

ge, when buffer zones of 350 meters are incorporated, and that most of the districts have a minimum distance of 100

meters between health facilities and pharmacies. It was concluded that the use of GIS proved to be very suitable for

analysis of pharmaceutical services, enabling knowledge of the local situation and serving as a stimulus for future studi-

es.

Keywords: Geographical Accessibility; Quality Pharmaceutical Service; Spatial Analysis; Distribution of Pharmacies;

Quality Assessment

1. Introduction

This study defines access to health services narrowly,

utilizing Avedis Donabedian’s conceptualization of geo-

graphical accessibility [1]. According to Donabedian, the

quality of health services can be assessed by attributes

that include socio-organizational and geographical ac-

cessibility. These two dimensions are interrelated and

express characteristics of health services that can facili-

tate or impede access by users. Geographical accessi-

bility refers to the location of supply and the location of

users, as well as the physical and temporal distance

patients must travel to get the care they need and/or want

[1-3].

When analyzing pharmaceutical services in Brazil

from the perspective of geographical accessibility, phar-

maceutical services, it is observed that the geographical

distribution of pharmacies is unordered, because there is

no federal law that establishes geographic and demo-

graphic criteria for the opening of new establishments.

Thus, pharmacies may accumulate in certain areas of the

city and exceed the ratio of pharmacies recommended by

the World Health Organization (one for every 6000 to

7000 people) [4]. This is in contrast to some European

countries, where there is specific legislation that guides

the distribution of pharmacies. In Portugal [5], for

example, legislation states that for a new pharmacy to be

installed, it must be at least 350 meters distant from other

pharmacies; a minimum distance of 100 meters between

the pharmacy and a health center or hospital must be

observed; and must be at least 3500 inhabitants. In other

*Corresponding a uthor.

Use of Spatial Analysis to Assess Geographic Accessibility of Community Pharmacies in São Mateus 439

European countries as well, the regulation of pharmacies

according to demographic and geographic criteria has

ensured the quality of pharmaceutical services [6].

While several cities in Brazil have developed laws

limiting the distance between pharmacies, they have not

always been implemented. Opponents argue that they are

unconstitutional and violate the principles of free com-

petition, freedom of exercise of economic activity, and

consumer law. There is also a lack of mechanisms that

would enable the zoning of pharmacies in order to meet

the provisions of such laws.

In this context, analysis of the spatial location of

health services through the use of Geographic Informa-

tion Systems (GIS) has an important role and is be-

coming more frequent within the area of public health.

Such analysis provides information about geographical

access vis-à-vis different socioeconomic factors, contri-

buting to the discussion of equity [7], while also contri-

buting new information on the spatial distribution of

diseases, health services and environmental hazards, thus

offering an important too l for connections between health

and the environment [8,9].

However, in the pharmaceutical area there are few

studies that use spatial analysis to assess the distribution

and quality of pharmaceutical services, partly due to the

lack of geographic and demographic criteria for the de-

ployment of new establishments. Thus, it is important to

understand geographical distribution and analyze its im-

pact on people, as part of an observed emphasis on ana-

lyzing the reality of pharmacy services and improving

the quality of the evolving pharmaceutical sector. Thus,

this study aims to contribute information in order to

better understand the spatial reality of the city of São

Mateus, with respect to the distribution of pharmacies

and health services, as well as the coverage area of com-

munity pharmacies and the demographic density of their

associated populations.

2. Materials and Methods

The study area was limited to the urban area of São

Mateus, Espírito Santo, Brazil (18˚43'04.97"S, 39˚51'

13.50"W). According to the synopsis of the 2010 census

compiled by the Brazilian Institute of Geography and

Statistics (IBGE), the city has a population of 109,028

inhabitants, a lan d area of 2343.15 square kilometers and

a population density of 46.53/km² [10].

The sample design consists of a cross-sectional

observational study, with the object of study comprising

private pharmacies located within the urban area and

possessing a technical supervisor (according to the Re-

gional Pharmacy Council of the Espírito Santo state).

Pharmacies located in the coastal area were excluded

because the distance from the downtown, as were public

pharmacies such as the “Farmácia Básica Municipal” and

the “Farmácia Cidadã Estadual”, because they provide

differentiated services, which could not be assessed with

a questionnaire proposed in this study. The research

project, No. 036/2010, was approved by the Research

Ethics Committee of the University Center North of

Espírito Santo, University of Espírito Santo (Opinion

001/2011).

The study used high-resolution images of the study

area (dimensions: 4484 × 3056 pix els, resolutio n: 91 dpi) ,

which are freely available on the Internet via the “Google

Earth” application. The information processing and digi-

tal modeling were performed by the GIS Idrisi Andes

Edition® (version 1.15-Clark University).

The image was georeferenced using the re-sample

module in Idrisi GIS. It was then necessary to perform

the scanning and separation into layers of all th e features

of interest in the study area, including streets, district

boundaries, pharmacies and health facilities (HF), using

the program CartaLinx®. The study utilized the addresses

of pharmacies, basic health units (BHU) and hospitals.

The decision to work this way (without using GPS) was

evaluated and accepted by the authors, in an effort to

achieve the most accurate results possible and given that

there are few differe nc e s generated by these met ho ds.

The demarcation of districts was not performed ac-

cording to an administrative definition, because the mu-

nicipality does not have legislation that establishes the

neighborhoods of the city. To achieve the required defi-

nitions, scanning was performed according to the regions

that had BHU and a map was constructed and defined by

local businesses. Thus, some quarters were grouped toge-

ther to form one district, totaling 12 neighb orhoods.

Analyses of the spatial distribution of pharmacies in

each district were also performed. Using the Idrisi Andes

edition®, buffer zones of 350 meters were created, based

on the Portuguese legislation [5] that guides the spatial

distribution of pharmacies. Also analyzed were the

number of HF in each neighborhood, including BHU,

hospitals and emergency care centers. A 100-meter buf-

fer zone was created for each pharmacy in order to assess

the presence of HF within that range (again, based on the

Portuguese legislation) [5].

Finally, we analyzed the number of pharmacies per

inhabitant. This assessment was also based on the Portu-

guese legislation [5], which requires a new pharmacy to

have a minimum range of 3500 inhabitants. However, the

lack of an official definition of neighborhoods in the city

prevented the attainment of demographic data by admini-

strative units, and left only the total number of inhabi-

tants supplied by IBGE. Thus, we used the number of

citizens served by the family health teams (ESF) and by

community health workers for each demarcated unit of

BHU (provided by the Health Department). This does not

faithfully portray the reality of the city, since BHU do

not have 100% coverage, but it was the most feasible and

reliable representation that could be used in this study.

Use of Spatial Analysis to Assess Geographic Accessibility of Community Pharmacies in São Mateus

440

Thus, the population density per pharmacy was calcu-

lated by dividing the number of inhabitants served by

BHU by the number of pharmacies in each district, and is

represented in the study by a thematic map.

3. Results and Discussion

The city of São Mateus, according to the Regional

Pharmacy Council of Espírito Santo, had 58 community

pharmacies in November 2010. Of these, 4 no longer

exist, 11 are not located in the study ar ea, 1 did not have

a pharmacist and 2 were public pharmacies (thus ex-

cluded from the study, as previously described). Thus, 40

pharmacies are georeferenced, as shown in Figure 1.

Community pharmacies in São Mateus are spatially

distributed unevenly, concentrated mainly in the center

of the city. Neighborhoods like Centro have accumulated

28 pharmacies while others, such as Aroeira, have no

pharmacies. This disorderly and inefficient distribution

of community pharmacies in the city may be due to the

predominant concept and practice of medicine as a con-

sumer product or commodity, as opposed to an instru-

ment in the service of health promotion, making a phar-

macy setting strictly commercial and profit-seeking. The

installation of pharmacies thus follows the requirements

for any other commercial establishment, abiding by the

principles of free competition, freedom of exercise of

economic activity, and consumer law, as determined by

the Federal Constitution [11].

However, analysis of the market aspects suggests that

the concentrated installation of pharmacies increases

competitiveness and, despite being a very lucrative

industry, decreases the stability of businesses and can

lead to their closure. Perhaps for this reason, the rapid

opening and closing of many pharmacies was observed

during the study. Moreover, this instability can lead to

Figure 1. Buffer Zones (350 m) of community pharmacies in

the city of São Mateus, ES. (1. Aroeira; 2. Bom Sucesso; 3.

Santo Antônio; 4. Vila Nova; 5. Boa Vista; 6. Cacique; 7.

Porto; 8. Centro; 9. Aviação; 10. Cohab; 11. Morada do Ri-

beirão; 12. Seac).

spending cuts, thereby reducing the investment structure

and organization of the pharmacy, its human resources

and even the drugs themselves, thus reducing the quality

of pharmaceutical services provided.

In addition, the current layout of pharmacies in th e city

reflects the past as well as the present, due to trends in

urban development. Perhaps the lack of pharmacies in

distant neighborhoods is due to the neighborhoods being

relatively new, since accumulated changes occur over

time [12].

Using the 350-meter buffer zone generated for each

pharmacy, we obtained the spatial extent of area phar-

macies. As can be seen in Figure 1, the accumulation of

pharmacies in some areas leaves a good part of the city

without pharmaceutical services. According to the calcu-

lation of the total area, only 43.7% of the study area

receives pharmaceutical services coverage.

The main aim of any pharmacy is to ensure a quality

pharmacy service to the public, where people can have

access, on equal terms; the drugs are safe and reliable,

resulting in improved quality of life; and pharmacists are

trained and operating within an appropriate structure and

organization. It is important that this is available to all,

and that patients can reach facilities to have access to

medicine.

The results found in São Mateus with respect to the

quality of service being offered are worrying. The accu-

mulation of pharmacies in the center of the city has

hindered access for the population located in remote

areas, who must expend greater effort, time and money to

obtain the necessary care.

Using the GIS Idrisi tool overlay, we obtained the

coverage area of pharmacies in each district, as shown in

Table 1. In some cases, districts did not have pharmacies

but were within the 350-meter buffer zone of neigh-

boring pharmacy services (for example, in Aviação,

Porto, Cacique and Bom Sucesso). While it was observed

that the neighborhoods with the greatest number of

Figure 2. Presence of HF Buffer Zones within 100 m of

community pharmacies in neighborhoods in the city of São

ateus, ES. M

Use of Spatial Analysis to Assess Geographic Accessibility of Community Pharmacies in São Mateus

441

Table 1. Distribution of results according to geographic and demographic variables and neighborhood.

Neighborhood Number of

pharmacies Number of basic

health units (BHU) Cover

area (%) Number of intersections

(350 m Buffer) Number of intersections

(100 m Buffer) Populatio

n Density

Aroeira 0 1 0 0 0 0

Bom Sucesso 0 1 1806 0 0 0

Boa Vista* 5 2 7077 5 1 0

Cacique 0 1 5675 5 0 0

Porto 0 1 8147 10 0 0

Aviação 0 1 3158 2 0 0

Centro 28 3 6673 247 3 15,857

Cohab 1 2 2492 0 0 4635

Seac 1 1 7571 0 0 3704

Morada do Ribeirão 0 1 0 0 0 0

Vila Nova 2 1 3857 3 0 2284

Santo Antônio 4 1 3759 2 0 2486,25

*Neighborhood witho ut Family Health Teams (ESF) or was not availab le the number of inha b it ants.

pharmacies had good coverage areas, the neighborhoods

of Cacique and Porto also had good coverage of phar-

maceutical services despite not having any pharmacies.

As noted, most pharmacies are located very close to

each other, even when located in different (but adjacent)

neighborhoods. This created a high number of inter-

sections between buffer zones, showing that the mini-

mum distance of 350 meters there is in many districts of

the municipality, as a Centro, Santo Antônio and Boa

Vista, extending this reality to the surrounding neigh-

borhoods, while not having pharmacies. Other neigh-

borhoods, such as Bom Sucesso, Seac and Cohab, only

have a few pharmacies but they are well distributed

throughout the neighborhood.

Regarding the presence of HF, it was observed that

every neighborhood had a BHU (which was, after all,

one of the criteria for defining the neighborhood para-

meters). In addition to the BHU, we spatially analyzed

the presence of hospitals and emergency care units, as

illustrated in Figure 2. For example, we noted the

presence of a hospital in th e neighborh oods of Coh ab and

Centro, in addition to the emergency care unit located in

the Boa Vista neigh borhood.

After creating the 100-meter buffer zones, the pre-

sence of HF located within the coverage area of phar-

macies was observed, as shown in Figure 2. Most neigh-

borhoods presented no HF in the coverage area; only

those with high numbers of pharmacies, such as Centro

and Boa Vista, did not possess the minimum distance of

100 meters suggested by the Portuguese legislation [5].

The distribution of pharmacies should be guided by

the location of HF, in order to complement the health

care services that are offered. However, the distance that

users must travel to obtain health care should be weight-

ed by the level of attention sought, since the distance to

more specialized services will be longer than for those

that require simpler levels of care [13].

Regarding the ratio of inhabitants to pharmacies,

Figure 3 shows that the values were far from those re-

commended by the Portuguese legislation [5]. As shown

in Table 1 , three districts have pharmacies serving fewer

than 3500 people. Of note is the Centro neighborhood,

with about 158 inhabitants per pharmacy, an extremely

low number. However, in more distant neighborhoods,

the presence of only one pharmacy was sufficient under

the Portuguese law, as seen in the neighborhoods of Co-

hab and Seac.

In countries with legislation that sets demograph ic and

geographic criteria for the establishment of new phar-

macies, the inhabitant-pharmacy ratios are very distant

from the values found in th is study. Austria, for example,

requires 5500 habitants per pharmacy. In France, the

ratio is determined by the size of the commune, ranging

from 2500 to 3500 inhabitants per pharmacy. In Italy, the

ratio requires more than 5000 inhabitants fo r populations

with fewer than 12,500 inhabitants, and 4000 for popu-

lations with more than 12,500 inhabitants. The average

number of inhabitants per pharmacy in Spain is 2099 [6].

Thus, the number of people covered by each pharmacy

in São Mateus is extremely low, compared to other

countries. However, the lack of demographic data that

more accurately represents the reality of each neighbor-

Use of Spatial Analysis to Assess Geographic Accessibility of Community Pharmacies in São Mateus

442

Figure 3. Categorization of districts according to population

density, the city of Sao Mateus, ES.

hood makes it difficult to evaluate these results with

certainty, and only provides a good idea of the situation

in São Mateus.

4. Conclusions

With this study, we conclude that the distribution of

community pharmacies in São Mateus is disorganized

and heterogeneous, depriving much of the population

access to pharmaceutical services and generating their

accumulation in certain districts. This is an unfavorable

development when analyses pharmacies as health faci-

lities. However, the research also highlights flaws in

municipal zoning; for example, the lack of delimitation

of administrative units impedes the acquisition of demo-

graphic data and more precise analysis of the results.

The use of GIS proved to be suitable for analysis of

pharmaceutical services, providing information on the

local situation and drawing attention to the distribution of

pharmacies. Its use also serves as a stimulus for future

studies and for the implementation of national and muni-

cipal-level regulations to guide the installation of these

health services.

Finally, this study shows the need for improvements in

the distribution of pharmaceutical services in the city, in

order to serve the entire population efficiently and with

quality. Moreover, additional studies of pharmaceutical

services and their quality are needed to better identify

local needs and develop public health strategies.

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