Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
BMC Health Services Research
Published in: BMC Health Services Research 1/2016

Open Access 01-12-2015 | Research article

Free establishment of primary health care providers: effects on geographical equity

Authors: David Isaksson, Paula Blomqvist, Ulrika Winblad

Published in: BMC Health Services Research | Issue 1/2016

Login to get access

Abstract

Background

A reform in 2010 in Swedish primary care made it possible for private primary care providers to establish themselves freely in the country. In the former, publicly planned system, location was strictly regulated by local authorities. The goal of the new reform was to increase access and quality of health care. Critical arguments were raised that the reform could have detrimental effects on equity if the new primary health care providers chose to establish foremost in socioeconomically prosperous areas.
The aim of this study is to examine how the primary care choice reform has affected geographical equity by analysing patterns of establishment on the part of new private providers.

Methods

The basis of the design was to analyse socio-economic data on individuals who reside in the same electoral areas in which the 1411 primary health care centres in Sweden are established. Since the primary health care centres are located within 21 different county councils with different reimbursement schemes, we controlled for possible cluster effects utilizing generalized estimating equations modelling. The empirical material used in the analysis is a cross-sectional data set containing socio-economic data of the geographical areas in which all primary health care centres are established.

Results

When controlling for the effects of the county council regulation, primary health care centres established after the primary care choice reform were found to be located in areas with significantly fewer older adults living alone as well as fewer single parents – groups which generally have lower socio-economic status and high health care needs. However, no significant effects were observed for other socio-economic variables such as mean income, percentage of immigrants, education, unemployment, and children <5 years.

Conclusions

The primary care choice reform seems to have had some negative effects on geographical equity, even though these seem relatively minor.
Appendix
Available only for authorised users
Literature
1.
Neutens T. Accessibility, equity and health care: review and research directions for transport geographers. J Transp Geogr. 2015;43:14–27.CrossRef
2.
Penchansky R, Thomas WJ. The Concept of Access: Definition and Relationship to Consumer Satisfaction. Med Care. 1981;19:127–40.CrossRefPubMed
3.
Luo W, Wang F. Measures of spatial accessibility to health care in a GIS environment: Synthesis and a case study in the Chicago region. Environ Plan B Plan Des. 2003;30:865–84.CrossRef
4.
Liu Y, Hsiao WC, Eggleston K. Equity in health and health care: the Chinese experience. Soc Sci Med. 1999;49:1349–56.CrossRefPubMed
5.
Rosero-Bixby L. Spatial access to health care in Costa Rica and its equity: a GIS-based study. Soc Sci Med. 2004;58:1271–84.CrossRefPubMed
6.
Dewulf B, Neutens T, De Weerdt Y, Van de Weghe N. Accessibility to primary health care in Belgium: an evaluation of policies awarding financial assistance in shortage areas. BMC Fam Pract. 2013;14:122.CrossRefPubMedPubMedCentral
7.
Goddard M, Gravelle H, Hole A, Marini G. Where did all the GPs go? Increasing supply and geographical equity in England and Scotland. J Health Serv Res Policy. 2010;15:28–35.CrossRefPubMed
8.
9.
Mackenbach JP, Bos V, Andersen O, Cardano M, Costa G, Harding S, et al. Widening socioeconomic inequalities in mortality in six Western European countries. Int J Epidemiol. 2003;32:830–7.CrossRefPubMed
10.
Dai D. Black residential segregation, disparities in spatial access to health care facilities, and late-stage breast cancer diagnosis in metropolitan Detroit. Health Place. 2010;16:1038–52.CrossRefPubMed
11.
Hiscock R, Pearce J, Blakely T, Witten K. Is neighborhood access to health care provision associated with individual-level utilization and satisfaction? Health Serv Res. 2008;43:2183–200.CrossRefPubMedPubMedCentral
12.
Higgs G. A Literature Review of the Use of GIS-Based Measures of Access to Health Care Services. Heal Serv Outcomes Res Methodol. 2004;5:119–39.CrossRef
13.
14.
15.
Lovett A, Haynes R, Sünnenberg G, Gale S. Car travel time and accessibility by bus to general practitioner services: a study using patient registers and GIS. Soc Sci Med. 2002;55:97–111.CrossRefPubMed
16.
Mitton C, Dionne F, Masucci L, Wong S, Law S. Innovations in health service organization and delivery in northern rural and remote regions: a review of the literature. Int J Circumpolar Health. 2012;70:460–72.CrossRef
17.
Asthana S, Gibson A, Moon G, Brigham P. Allocating resources for health and social care: the significance of rurality. Heal Soc Care Community. 2003;11:486–93.CrossRef
18.
Wakerman J, Humphreys JS, Wells R, Kuipers P, Entwistle P, Jones J. Primary health care delivery models in rural and remote Australia – a systematic review. BMC Health Serv Res. 2008;8:276.CrossRefPubMedPubMedCentral
19.
Asthana S, Halliday J. What can rural agencies do to address the additional costs of rural services? A typology of rural service innovation. Heal Soc Care Community. 2004;12:457–65.CrossRef
20.
Powell Davies G, Williams AM, Larsen K, Perkins D, Roland M, Harris MF. Coordinating primary health care: an analysis of the outcomes of a systematic review. Med J Aust. 2008;188:S65–8.PubMed
21.
22.
Wen M, Hawkley LC, Cacioppo JT. Objective and perceived neighborhood environment, individual SES and psychosocial factors, and self-rated health: An analysis of older adults in Cook County, Illinois. Soc Sci Med. 2006;63:2575–90.CrossRefPubMed
23.
Patel KV, Eschbach K, Rudkin LL, Peek MK, Markides KS. Neighborhood context and self-rated health in older Mexican Americans. Ann Epidemiol. 2003;13:620–8.CrossRefPubMed
24.
Sundquist K, Malmström M, Johansson S-E. Neighbourhood deprivation and incidence of coronary heart disease: a multilevel study of 2.6 million women and men in Sweden. J Epidemiol Community Health. 2004;58:71–7.CrossRefPubMedPubMedCentral
25.
Buka S, Brennan R, Rich-Edwards J, Raudenbush S, Earls F. Neighborhood Support and the Birth Weight of Urban Infants. Am J Epidemiol. 2003;158:1023–32.CrossRef
26.
Szwarcwald CL, De Andrade CLT, Bastos FI. Income inequality, residential poverty clustering and infant mortality: A study in Rio de Janeiro, Brazil. Soc Sci Med. 2002;55:2083–92.CrossRefPubMed
27.
Bissonnette L, Wilson K, Bell S, Shah TI. Neighbourhoods and potential access to health care: The role of spatial and aspatial factors. Health Place. 2012;18:841–53.CrossRefPubMed
28.
Korda RJ, Butler JRG, Clements MS, Kunitz SJ. Differential impacts of health care in Australia: Trend analysis of socioeconomic inequalities in avoidable mortality. Int J Epidemiol. 2007;36:157–65.CrossRefPubMed
29.
Arcury TA, Gesler WM, Preisser JS, Sherman J, Spencer J, Perin J. The effects of geography and spatial behavior on health care utilization among the residents of a rural region. Health Serv Res. 2005;40:135–55.CrossRefPubMedPubMedCentral
30.
Shaw N, Hegedus G. The National Programme for Information Technology: The GP as gatekeeper - A bastion worth fighting for? Br J Gen Pract. 2005;55:85–6.PubMedPubMedCentral
31.
LaVela SL, Smith B, Weaver FM, Miskevics SA. Geographical proximity and health care utilization in veterans with SCI&D in the USA. Soc Sci Med. 2004;59:2387–99.CrossRefPubMed
32.
McCarthy JF, Blow FC. Older patients with serious mental illness: sensitivity to distance barriers for outpatient care. Med Care. 2004;42:1073–80.CrossRefPubMed
33.
Guthrie B, McLean G, Sutton M. Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract. Br J Gen Pract. 2006;56:836–41.PubMedPubMedCentral
34.
Doran T, Fullwood C, Gravelle H, Reeves D, Kontopantelis E, Hiroeh U, et al. Pay-for-performance programs in the United Kingdom. N Engl J Med. 2006;355:375–84.CrossRefPubMed
35.
Newhouse JP, Williams AP, Bennett BW, William B. Does the geographical distribution of physicians reflect market failure ? Bell J Econ. 1982;13:493–505.CrossRef
36.
Fredriksson M, Blomqvist P, Winblad U. The trade-off between choice and equity: Swedish policymakers’ arguments when introducing patient choice. J Eur Soc Policy. 2013;23:192–209.CrossRef
37.
Rehnberg C, Nils J, Khan J, Lundgren J. Uppföljning Av Husläkarsystemet Inom Vårdval Stockholm. Stockholm: Karolinska Institutets folkhälsoakademi; 2010.
38.
Riksrevisionen: Primärvårdens Styrning - Efter Behov Eller Efterfrågan? Stockholm; 2014.
39.
Kringos D, Boerma W, Hutchinson A, Saltman RB: Building Primary Care in a Changing Europe. 2015(Observatory Studies Series 38).
40.
Anell A, Glenngård AH, Merkur S. Health Systems in Transition - Sweden Health system review. Health Syst Transit. 2012;14:187.
41.
Blomqvist P, Winblad U. Sweden: Continued Marketization within a Universalist System. In: Pavolini E, Guillén MA, editors. Health Care Systems in Europe under Austerity - Institutional Reforms and Performance. 1st ed. Basingstoke: Palgrave Macmillan; 2013. p. 9–30.CrossRef
42.
Andersson F, Janlöv N, Rehnberg C. Konkurrens, Kontrakt och Kvalitet - Hälso- och sjukvård i privat regi. Stockholm: Finansdepartementet, Regeringskansliet; 2014.
43.
Glenngård, AH. Primärvården efter vårdvalsreformen. Stockholm: SNS Förlag; 2015.
44.
Saltman RB, Bergman S-E. Renovating the Commons: Swedish health care reforms in perspective. J Health Polit Policy Law. 2005;30:253–75.CrossRefPubMed
45.
Winblad U, Blomqvist P. Preserving social equity in privatized primary care: a matter of contract design. London: EHPG; 2015.
46.
Winkleby MA, Jatulis DE, Frank E, Fortmann SP. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Heal. 1992;82:816–20.CrossRef
47.
Cutler DM, Lleras-muney A: Education and Health: Evaluating Theories and Evidence. Cambridge, MA; 2006. [Working Paper 12352]
48.
Montgomery SM, Cook DG, Bartley MJ, Wadsworth MEJ. Unemployment pre-dates symptoms of depression and anxiety resulting in medical consultation in young men. Int J Epidemiol. 1999;28:95–100.CrossRefPubMed
49.
Kharicha K, Iliffe S, Harari D, Swift C, Gillmann G, Stuck A. Health risk appraisal in older people 1: are older people living alone an ‘at-risk’group? Br J Gen Pract. 2007;537:271–6.
50.
Hubbard AE, Ahern J, Fleischer NL, Van der Laan M, Lippman SA, Jewell N, et al. To GEE or not to GEE: comparing population average and mixed models for estimating the associations between neighborhood risk factors and health. Epidemiology. 2010;21:467–74.CrossRefPubMed
51.
Cui J, Qian G. Selection of Working Correlation Structure and Best Model in GEE Analyses of Longitudinal Data. Commun Stat - Simul Comput. 2007;36:987–96.CrossRef
52.
Begg MD, Parides MK. Separation of individual-level and cluster-level covariate effects in regression analysis of correlated data. Stat Med. 2003;22(August 2002):2591–602.CrossRefPubMed
53.
Overall JE, Tonidandel S. Robustness of Generalized Estimating Equation (GEE) tests of significance against misspecification of the error structure model. Biometrical J. 2004;46:203–13.CrossRef
54.
R Core Team: R: A language and environment for statistical computing. 2015.
55.
Halekoh U, Højsgaard S. The R package geepack for generalized estimating equations. J Stat Softw. 2006;15:1–11.CrossRef
56.
Domberger S, Jensen P. Contracting out by the public sector: theory, evidence, prospects. Oxford Rev Econ policy. 1997;13:67–78.CrossRef
57.
Anell A. Choice and privatisation in Swedish primary care. Health Econ Policy Law. 2011;6:549–69.CrossRefPubMed
58.
Dahlgren G. Neoliberal Reforms in Swedish Primary Health Care: For Whom and for What Purpose? Int J Heal Serv. 2008;38:697–715.CrossRef
59.
Winblad U, Isaksson D, Bergman P. Effekter Av Valfrihet Inom Hälso- Och Sjukvård – En Kartläggning Av Kunskapsläget. Stockholm: Myndigheten för vårdanalys; 2012.
Metadata
Title
Free establishment of primary health care providers: effects on geographical equity
Authors
David Isaksson
Paula Blomqvist
Ulrika Winblad
Publication date
01-12-2015
Publisher
BioMed Central
Published in
BMC Health Services Research / Issue 1/2016
Electronic ISSN: 1472-6963
DOI
https://doi.org/10.1186/s12913-016-1259-z

Other articles of this Issue 1/2016

BMC Health Services Research 1/2016 Go to the issue

Research article

Integrating care for frequent users of emergency departments: implementation evaluation of a brief multi-organizational intensive case management intervention

Research article

Follow-up and tracing of tuberculosis patients who fail to attend their scheduled appointments in Cotonou, Benin: a retrospective cohort study

Research article

Exploration of social factors associated to maternal deaths due to haemorrhage and convulsions: Analysis of 28 social autopsies in rural Bangladesh

Research article

Comparing healthcare utilization among health survey respondents with the total population – are respondents representative?

Research article

Assessment of a multimedia-based prospective method to support public deliberations on health technology design: participant survey findings and qualitative insights

Research article

Health profiles of foreigners attending primary care clinics in Malaysia