Spatial inequities and efficiency limits in home-based palliative care: the empirical study from a Chinese province

China’s rising demand for home-based palliative care (HPC) creates a critical challenge for the health system: balancing equitable access with efficient resource allocation. While integration into primary health care (PHC) has been widely adopted as the core strategy, evidence regarding its effectiveness remains limited. This study aims to evaluate the equity, efficiency and system coordination of HPC resources allocation within the PHC system. Based on longitudinal survey data collected by the research team from all community health centers in Shanghai, we assessed the equity of PHC-based HPC resources allocation using the Gini coefficients, the health resource density index and the Dagum decomposition, and evaluated its efficiency using a DEA-SBM model and the Malmquist productivity index. The coordination between resource provision and efficiency was examined using quadrant analysis and the coupling coordination degree model. From 2019 to 2023, PHC-based HPC resources expanded substantially, with HPC beds increasing by 80.7%. However, spatial inequity persisted. Allocation by population was relatively equitable, whereas geographic allocation remained markedly inequitable, with inter-regional differences contributing more than 77% of overall inequity. Overall efficiency fluctuated between 0.627 and 0.701, with pure technical efficiency declining while scale efficiency improved. Productivity grew modestly with a mean total factor productivity change of 1.007, driven mainly by technological progress but constrained by declining technical efficiency. Although the coupling coordination degree rose from 0.526 to 0.648, the system had not yet achieved a state of high coordination. PHC-based HPC resources allocation in Shanghai improved in scale and population-based equity, yet geographic unevenness persisted, efficiency improvements remained limited, and the coordination between resource provision and efficiency improved incrementally. Expansion alone was insufficient to achieve integrated and balanced system performance. Future reforms should prioritize geography-sensitive allocation, stronger capacity in underserved areas, and better organizational and management support to foster a more equitable, efficient, and coordinated PHC-based HPC system.