Accessibility to primary health care in Belgium: an evaluation of policies awarding financial assistance in shortage areas

Background: In many countries, financial assistance is awarded to physicians who settle in an area that is designated as a shortage area to prevent unequal accessibility to primary health care. Today, however, policy makers use fairly simple methods to define health care accessibility, with physician-to-population ratios (PPRs) within predefined administrative boundaries being overwhelmingly favoured. Our purpose is to verify whether these simple methods are accurate enough for adequately designating medical shortage areas and explore how these perform relative to more advanced GIS-based methods. Methods: Using a geographical information system (GIS), we conduct a nation-wide study of accessibility to primary care physicians in Belgium using four different methods: PPR, distance to closest physician, cumulative opportunity, and floating catchment area (FCA) methods. Results: The official method used by policy makers in Belgium (calculating PPR per physician zone) offers only a crude representation of health care accessibility, especially because large contiguous areas (physician zones) are considered. We found substantial differences in the number and spatial distribution of medical shortage areas when applying different methods. Conclusions: The assessment of spatial health care accessibility and concomitant policy initiatives are affected by and dependent on the methodology used. The major disadvantage of PPR methods is its aggregated approach, masking subtle local variations. Some simple GIS methods overcome this issue, but have limitations in terms of conceptualisation of physician interaction and distance decay. Conceptually, the enhanced 2-step floating catchment area (E2SFCA) method, an advanced FCA method, was found to be most appropriate for supporting areal health care policies, since this method is able to calculate accessibility at a small scale (e.g. census tracts), takes interaction between physicians into account, and considers distance decay. While at present in health care research methodological differences and modifiable areal unit problems have remained largely overlooked, this manuscript shows that these aspects have a significant influence on the insights obtained. Hence, it is important for policy makers to ascertain to what extent their policy evaluations hold under different scales of analysis and when different methods are used

Concepts, reflections and applications of social equity: approaches to accessibility to primary goods and services in the region of Flanders, Belgium

Mobility presents a variety of opportunities as it allows users to access locations and services, and to meet people beyond their immediate surroundings. While the concept of mobility primarily focuses on the ease of moving, accessibility delineates the actual potential to participate in out-of-home activities. As a result, accessibility is a complex concept with a multitude of foci. This complexity is presented in the first section, which explains the general concept of accessibility, how it is defined and how it is related to the notion of transport-related exclusion. This section also gives an overview of the body of literature on the measures to determine area-based as well as personal accessibility levels and points out the important contrast between the simple, easy-to-interpret methods, adopted by policy makers and the complex methods preferred by experts. The second section clarifies how the dichotomous relationship between the urban and rural environment is reflected in transport policy that emphasizes on (especially car-based) mobility rather than on accessibility. Furthermore, the environmental and economic points of view are highlighted and the common policy strategies focused on sustainability are illustrated. Subsequently, the shortcomings in the way in which the contemporary debates concerning mobility, sustainability and the social implications of transport planning are conducted, are criticized. Finally, the last part of this section is dedicated to an extensive discussion on the ability of transport policies to, on the one hand, generate spatially as well as temporally uneven accessibility effects that give preference to certain population groups above others, and on the other hand, their ability to strive for a more equitable distribution of transport services amongst the population. The third section proposes two methodologies for measuring transport-related social exclusion implemented in a literature-based case study in Flanders. These studies comprise the following topics: measuring transport gaps by relating the social to the transport disadvantage and measuring modal disparities by comparing accessibility by private and public transport. The former investigates in which areas the provision of the public transport system is not tailored to specific public transport needs. The latter examines the disparity in access by private and public transport in order to highlight the car dependency. Both case studies incorporate the temporal variability in provision through the private and public transport network, as the time-of-day strongly influences accessibility levels

Modeling Multimodal Access to Primary Care in an Urban Environment

Access to primary health care facilities is a key component of public health, and measuring that access is vital to understanding how to target interventions. Transportation is one dimension of access and measuring distance via multiple modes allows better understanding of how varied populations access health care, particularly those who do not have access to a personal vehicle. This work builds on the 2-Step Floating Catchment Area (2SFCA) method to include travel by car, bus, bicycle, and walking. Travel time data are sourced from OpenStreetMap and transit data incorporates stop and schedule information from the General Transit Feed Specification (GTFS). Open source data analysis tools are used to aid reproducibility in other geographic contexts. Modal weights are assigned to measure the population accessing each facility by each mode. Access values for Milwaukee County in Wisconsin, USA are presented, with clear differences shown among modes accessing primary healthcare. Car access is high and consistent across the county, while biking and walking access are more impacted by distance to destination. Transit access is unequal across the county with some tracts showing no access at all. The highly varied access results by mode emphasize the importance of measuring access and travel by non-car modes, particularly when targeting communities with high rates of no car ownership. Improvement of multimodal access measurement will allow for targeted interventions that account for the availability of modes in each community

Spatial access to inpatient health care in northern rural India

Access to health care in rural areas is a major concern for local populations as well as for policy makers in developing countries. This paper examines spatial access to in-patient health care in northern rural India. In order to measure spatial access, impedance-based competition using the Three-Step floating Catchment Area (3SFCA) method, a modification of the simple gravity model, was used. 3SFCA was chosen for the study of the districts of Pratapgarh and Kanpur Dehat in the Uttar Pradesh state and Vaishali in the Bihar state, two of India’s poorest states. This approach is based on discrete distance decay and also considers more parameters than other available methods, hence is believed to be a robust methodology. It was found that Vaishali district has the highest spatial access to in-patient health care followed by Pratapgarh and Kanpur Dehat. There is serious lack of health care, in Pratapgarh and Kanpur Dehat with 40% and 90% of the villages having shortage of in-patient care facilities in these respective districts. The most important factor affecting spatial access was found to be the distance to the nearest major urban agglomeratio

Spatial accessibility and social inclusion: The impact of Portugal's last health reform

Health policies seek to promote access to health care and should provide appropriate geographical accessibility to each demographical functional group. The dispersal demand of health‐careservices and the provision for such services atfixed locations contribute to the growth of inequality intheir access. Therefore, the optimal distribution of health facilities over the space/area can lead toaccessibility improvements and to the mitigation of the social exclusion of the groups considered mostvulnerable. Requiring for such, the use of planning practices joined with accessibility measures. However,the capacities of Geographic Information Systems in determining and evaluating spatial accessibility inhealth system planning have not yet been fully exploited. This paper focuses on health‐care services planningbased on accessibility measures grounded on the network analysis. The case study hinges on mainlandPortugal. Different scenarios were developed to measure and compare impact on the population'saccessibility. It distinguishes itself from other studies of accessibility measures by integrating network data ina spatial accessibility measure: the enhanced two‐stepfloating catchment area. The convenient location forhealth‐care facilities can increase the accessibility standards of the population and consequently reducethe economic and social costs incurred. Recently, the Portuguese government implemented a reform thataimed to improve, namely, the access and equity in meeting with the most urgent patients. It envisaged,in terms of equity, the allocation of 89 emergency network points that ensured more than 90% of thepopulation be within 30 min from any one point in the network. Consequently, several emergency serviceswere closed, namely, in rural areas. This reform highlighted the need to improve the quality of the emergencycare, accessibility to each care facility, and equity in their access. Hence, accessibility measures becomean efficient decision‐making tool, despite its absence in effective practice planning. According to anapplication of this type of measure, it was possible to verify which levels of accessibility were decreased,including the most disadvantaged people, with a larger time of dislocation of 12 min between 2001 and 2011

The shortage-surplus paradox : a literature review of primary health care accessibility

The National Primary Health Care Strategy in Australia recommends primary health care services need to be clinically and culturally appropriate and delivered in a timely and affordable manner. However simultaneously recognised, access is still inequitable in among various population groups and many areas of Australia. Geographical Information System (GIS) have been used to explore geographical health disparities, planning health care service delivery and provide data in a meaningful way to inform public health strategies. Moreover, GIS has also been used to spatially analyse, measure and provide insight into a population’s accessibility to health care services. A literature search was conducted to identify studies which examined primary health care accessibility using GIS techniques among various urban and rural populations. A limited number of studies demonstrated in addition to distance; time; and location, low socioeconomic status, Culturally and Linguistically Diverse (CALD) background among other factors influences health care access. In addition, other factors were identified to impact health care access, which is an individualised process, influenced by individual characteristics, beliefs, attitudes, and an individual’s activity space. As health care accessibility becomes more prominent within policy, among practitioners and increasingly researched, it has the potential to move beyond recognising areas of poor accessibility among individuals and communities. With a greater integration of both spatial and aspatial data, the process has the likelihood, to provide greater insight into patient behaviour, public perception, amelioration service quality and improve population health and wellbeing

Evaluating the Methodology and Clinical Utility of Spatial Access to Health Care Measures in Appalachia.

The Appalachia region of the U.S. has noted socioeconomic disparities, elevated rates and mortality for many cancers, and substandard cancer treatment patterns. These disparities, combined with Appalachia’s largely rural population, suggest that the region has reduced access to health care. This research investigated the methodology behind spatial access to healthcare using population-based clinical data and geographic information systems (GIS) software. The dissertation’s goal was to provide a guide of the latest spatial access methods in Appalachia and to demonstrate how those methods can be incorporated into models studying cancer disparities in the region. Accredited mammography centers and primary care physicians in 2008 from Pennsylvania, Ohio, Kentucky, and North Carolina, along with U.S. Census population data, were geocoded into GIS software. Methods compared included ratios of mammography centers and physicians to county populations, travel time to closest mammography centers and physicians, and several versions of the newer two-step floating catchment area (2SFCA) method, which has never been evaluated in Appalachia. As a measure of predictive validity, spatial access methods were then used to predict two important breast cancer clinical indicators: stage at diagnosis and receipt of adjuvant hormonal therapy after a qualifying surgery. Urban and non-Appalachia areas had consistently shorter travel times than the rural and Appalachia areas of the same states, across both travel times to mammography centers and primary care physicians. The 2SFCA measures that included variable catchment sizes appeared distinct from the original 2SFCA method and 2SFCA methods that included distance decay weights but no variable catchments. Predictors of late-stage breast cancer diagnosis included age, insurance status, county primary care to population ratio, and primary care 2SFCA score. Geographically weighted logistic regression revealed that the effect of the predictor variables varied throughout the study region. Predictors of adjuvant hormonal therapy included the presence of multiple diseases, county economic status, and mammography center 2SFCA score. Overall, the 2SFCA method with variable catchment sizes offered the greatest predictive validity of the access measures and offers theoretical improvements over the other access to care measures. Nonetheless, further research is needed to validate the 2SFCA method parameters with patient healthcare utilization data.PhDBioinformaticsUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/111545/1/joedonoh_1.pd

Spatio-temporal analysis of spatial accessibility to primary health care in Bhutan

© 2015 by the authors; licensee MDPI, Basel, Switzerland. Geographic information systems (GIS) can be effectively utilized to carry out spatio-temporal analysis of spatial accessibility to primary healthcare services. Spatial accessibility to primary healthcare services is commonly measured using floating catchment area models which are generally defined with three variables; namely, an attractiveness component of the service centre, travel time or distance between the locations of the service centre and the population, and population demand for healthcare services. The nearest-neighbour modified two-step floating catchment area (NN-M2SFCA) model is proposed for computing spatial accessibility indices for the entire country. Accessibility values from 2010 to 2013 for Bhutan were analysed both spatially and temporally by producing accessibility ranking maps, plotting Lorenz curves, and conducting spatial clustering analysis. The spatial accessibility indices of the 205 sub-districts show great disparities in healthcare accessibility in the country. The mean-and median-based classification results indicate that, in 2013, 24 percent of Bhutan's population have poor access to primary healthcare services, 66 percent of the population have medium-level access, and 10 percent have good access

Measuring Primary Health Care Accessibility in Mississippi State Using an Extended Kernel Density 2SFCA Method

The accessibility of primary health care is fundamentally important to people’s life quality and wellbeing. Based on the block group level 2010 census data from the U.S. Census Bureau and primary health care data from Association of American Medical Colleges, this study focuses on measuring the primary health care accessibility using an extended kernel-density two Step Float Catchment Area method. The study area is the Mississippi State, which is ranked last state for health care. The objectives of this study are to calculate the accessibility and analyze the spatial and non-spatial disadvantages of communities in accessibility of primary health care of the Mississippi State. Results showed that the two-step floating catchment area integrated by a Gaussian function method is a viable method of calculating accessibility. Overall, urban and the fringe areas have higher spatial accessibility to primary health care, while lower accessibility areas are the suburban and rural areas. Relatively, Hinds County, Madison County, Rankin County, Lamer County, Forrest County, Jones County, Lauderdale County, and Lee County have higher accessibility, while some counties have lower accessibility, such as Marshall County, Winston County, Noxubee County, Wilkinson County, Smith County, and Greene County. From the factor analysis, those urban areas showed greater mobility disadvantages and higher health care needs. Besides, the attempts to integrate the health needs index and the mobility index with the spatial accessibility helps to balance accessibility with different non-spatial conditions. Additionally, this study provides implications for public policy about the health care distribution and the high health needs population