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

A novel application of interrupted time series analysis to identify the impact of a primary health care reform on intersectional inequities in avoidable hospitalizations in the adult Swedish population

Primary health care (PHC) systems are a crucial instrument for achieving equitable population health, but there is little evidence of how PHC reforms impact equities in population health. In 2010, Sweden implemented a reform that promoted marketization and privatization of PHC. The present study uses a novel integration of intersectionality-informed and evaluative epidemiological analytical frameworks to disentangle the impact of the 2010 Swedish PHC reform on intersectional inequities in avoidable hospitalizations. The study population comprised the total Swedish population aged 18-85 years across 2001-2017, in total 129 million annual observations, for whom register data on sociodemographics and hospitalizations due to ambulatory care sensitive conditions were retrieved. Multilevel Analysis of Individual Heterogeneity and Discriminatory Analyses (MAIHDA) were run for the pre-reform (2001-2009) and post-reform (2010-2017) periods to provide a mapping of inequities. In addition, random effects estimates reflecting the discriminatory accuracy of intersectional strata were extracted from a series MAIHDAs run per year 2001-2017. The estimates were re-analyzed by Interrupted Time Series Analysis (ITSA), in order to identify the impact of the reform on measures of intersectional inequity in avoidable hospitalizations. The results point to a complex reconfiguration of social inequities following the reform. While the post-reform period showed a reduction in overall rates of avoidable hospitalizations and in age disparities, socioeconomic inequities in avoidable hospitalizations, as well as the importance of interactions between complex social positions, both increased. Socioeconomically disadvantaged groups born in the Nordic countries seem to have benefited the least from the reform. The study supports a greater attention to the potentially complex consequences that health reforms can have on inequities in health and health care, which may not be immediate apparent in conventional evaluations of either population-average outcomes, or by simple evaluations of equity impacts. Methodological approaches for evaluation of complex inequity impacts need further development.

Trajectories of primary health care utilization: a 10-year follow-up after the Swedish Patient Choice Reform of primary health care

BACKGROUND

In January 2010, the choice reform was instituted in Swedish primary health care establishing free entry for private primary health care providers and enabling patients to choose freely among primary health care centers. The motivation behind the reform was to improve access to primary care and responsiveness to patient expectations. Reform effects on health care utilization have previously been investigated by using subgroup analyses assuming a pattern of homogeneous subgroups of the population. By using a different methodological approach, the aim of this study was to, from an equity perspective, investigate long term trends of primary health care utilization following the choice reform.

METHOD

A closed cohort was created based on register data from Region Skåne, the third most populated region in Sweden, describing individuals' health care utilization between 2007-2017. Using a novel approach, utilization data, measured as primary health care visits, was matched with socioeconomic and geographic determinants, and analyzed using logistic regression models.

RESULTS

A total of 659,298 individuals were included in the cohort. Sex differences in utilization were recorded to decrease in the older age group and to increase in the younger age group. Multivariable logistic regression showed increasing utilization in older men to be associated with higher socioeconomic position, while in women it was associated with lower socioeconomic position. Furthermore, groups of becoming high utilizers were all associated with lower socioeconomic position and with residence in urban areas.

CONCLUSION

The impact of demographic, socioeconomic and geographic determinants on primary health care utilization varies in magnitude and direction between groups of the population. As a result, the increase in utilization as observed in the general population following the choice reform is unevenly distributed between different population groups.

Understanding primary care transformation and implications for ageing populations and health inequalities: a systematic scoping review of new models of primary health care in OECD countries and China

BACKGROUND

Many countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key 'components', impacts of new models of care, and barriers and facilitators to PCT implementation.

METHODS

We undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym ). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed.

RESULTS

A total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with  < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes.

CONCLUSIONS

Countries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.

Performing up to Nordic principles? Geographic and socioeconomic equity in ambulatory care sensitive conditions among older adults in capital areas of Denmark, Finland and Sweden in 2000-2015

BACKGROUND

Denmark, Finland and Sweden pursue equity in health for their citizens through universal health care. However, it is unclear if these services reach the older adult population equally across different socioeconomic positions or living areas. Thus, we assessed geographic and socioeconomic equity in primary health care (PHC) performance among the older adults in the capital areas of Denmark (Copenhagen), Finland (Helsinki) and Sweden (Stockholm) in 2000-2015. Hospitalisations for ambulatory care sensitive conditions (ACSC) were applied as a proxy for PHC performance.

METHODS

We acquired individual level ACSCs for those aged ≥ 45 in 2000-2015 from national hospitalisation registers. To identify whether the disparities varied by age, we applied three age groups (those aged 45-64, 65-75 and ≥ 75). Socioeconomic disparities in ACSCs were described with incidence rate ratios (IRR) and annual rates by education, income and living-alone; and then analysed with biennial concentration indices by income. Geographic disparities were described with biennial ACSC rates by small areas and analysed with two-level Poisson multilevel models. These models provided small area estimates of IRRs of ACSCs in 2000 and their slopes for development over time, between which Pearson correlations were calculated within each capital area. Finally, these models were adjusted for income to distinguish between geographic and socioeconomic disparities.

RESULTS

Copenhagen had the highest IRR of ACSCs among those aged 45-64, and Helsinki among those aged ≥ 75. Over time IRRs decreased among those aged ≥ 45, but only in Helsinki among those aged ≥ 75. All concentration indices slightly favoured the affluent population but in Stockholm were mainly non-significant. Among those aged ≥ 75, Pearson correlations were low in Copenhagen (-0.14; p = 0.424) but high in both Helsinki (-0.74; < 0.001) and Stockholm (-0.62; < 0.001) - with only little change when adjusted for income. Among those aged ≥ 45 the respective correlations were rather similar, except for a strong correlation in Copenhagen (-0.51, 0.001) after income adjustment.

CONCLUSIONS

While socioeconomic disparities in PHC performance persisted among older adults in the three Nordic capital areas, geographic disparities narrowed in both Helsinki and Stockholm but persisted in Copenhagen. Our findings suggest that the Danish PHC incorporated the negative effects of socio-economic segregation to a lesser degree.

Successes, weaknesses, and recommendations to strengthen primary health care: a scoping review

BACKGROUND

Primary health care (PHC) is a roadmap for achieving universal health coverage (UHC). There were several fragmented and inconclusive pieces of evidence needed to be synthesized. Hence, we synthesized evidence to fully understand the successes, weaknesses, effective strategies, and barriers of PHC.

METHODS

We followed the PRISMA extension for scoping reviews checklist. Qualitative, quantitative, or mixed-approach studies were included. The result synthesis is in a realistic approach with identifying which strategies and challenges existed at which country, in what context and why it happens.

RESULTS

A total of 10,556 articles were found. Of these, 134 articles were included for the final synthesis. Most studies (86 articles) were quantitative followed by qualitative (26 articles), and others (16 review and 6 mixed methods). Countries sought varying degrees of success and weakness. Strengths of PHC include less costly community health workers services, increased health care coverage and improved health outcomes. Declined continuity of care, less comprehensive in specialized care settings and ineffective reform were weaknesses in some countries. There were effective strategies: leadership, financial system, 'Diagonal investment', adequate health workforce, expanding PHC institutions, after-hour services, telephone appointment, contracting with non-governmental partners, a 'Scheduling Model', a strong referral system and measurement tools. On the other hand, high health care cost, client's bad perception of health care, inadequate health workers, language problem and lack of quality of circle were barriers.

CONCLUSIONS

There was heterogeneous progress towards PHC vision. A country with a higher UHC effective service coverage index does not reflect its effectiveness in all aspects of PHC. Continuing monitoring and evaluation of PHC system, subsidies to the poor, and training and recruiting an adequate health workforce will keep PHC progress on track. The results of this review can be used as a guide for future research in selecting exploratory and outcome parameters.

Organizational influences on the use of low-value care in primary health care - a qualitative interview study with physicians in Sweden

AIM

The aim was (1) to explore organizational factors influencing the use of low-value care (LVC) as perceived by primary care physicians and (2) to explore which organizational strategies they believe are useful for reducing the use of LVC.

DESIGN

Qualitative study with semi-structured focus group discussions (FGDs) analyzed using qualitative content analysis.

SETTING

Six publicly owned primary health care centers in Stockholm.

SUBJECTS

The participants were 31 primary care physicians. The number of participants in each FGD varied between 3 and 7.

MAIN OUTCOME MEASURES

Categories and subcategories reporting organizational factors perceived to influence the use of LVC and organizational strategies considered useful for reducing the use of LVC.

RESULTS

Four types of organizational factors (resources, care processes, improvement activities, and governance) influenced the use of LVC. Resources involved time to care for patients, staff knowledge, and working tools. Care processes included work routines and the ways activities and resources were prioritized in the organization. Improvement activities involved performance measurement and improvement work to reduce LVC. Governance concerned organizational goals, higher-level decision making, and policies. Physicians suggested multiple strategies targeting these factors to reduce LVC, including increased patient-physician continuity, adjusted economic incentives, continuous professional development for physicians, and gatekeeping functions which prevent unnecessary appointments and guide patients to the appropriate point of care. .

CONCLUSION

The influence of multiple organizational factors throughout the health-care system indicates that a whole-system approach might be useful in reducing LVC.KEY POINTSWe know little about how organizational factors influence the use of low-value care (LVC) in primary health care.Physicians perceive organizational resources, care processes, improvement activities, and governance as influences on the use of LVC and LVC-reducing strategies.This study provides insights about how these factors influence LVC use.Strategies at multiple levels of the health-care system may be warranted to reduce LVC.

Job demands, job resources, and health outcomes among nursing professionals in private and public healthcare sectors in Sweden - a prospective study

Background

Nursing professionals exhibit high prevalence of stress-related health problems. Job demands and job resources are parallel drivers of health and well-being among employees. Better job resources associate with better job satisfaction, job motivation and engagement even when job demands are high. To date, there is limited research which explores the association between job demands, job resources and health outcomes among nursing professionals in the Swedish context. The aim of this study was therefore to investigate Swedish nursing professionals’ job demands and job resources in relation to health outcomes, with comparisons between the private and public healthcare sectors. The specific research questions were as follows: (1) Are there differences between private and public healthcare regarding job demands, job resources, and health outcomes? and (2) Are there prospective associations between job demands and job resources in relation to health outcomes?

Methods

Data were drawn from the Swedish Longitudinal Occupational Survey of Health (SLOSH) 2016 and 2018, including 520 nurses and 544 assistant nurses working in the private and public healthcare sectors from 2016 (baseline). Data were analyzed using binary logistic regression.

Results

Nursing professionals reported higher threats, lower bullying, lower control, lower social support, and lower cohesion in the public healthcare units compared to the private healthcare units. The prospective analyses showed that job resources in terms of social support and rewards were associated with higher self-rated health and lower burnout. Cohesion was associated with higher self-rated health. Job demands in terms of psychological demands and job efforts were associated with lower self-rated health, higher burnout, and higher sickness absence, while emotional demands were associated with higher burnout.

Conclusions

Nursing professionals’ job resources are deficient in public healthcare units. Job resources are associated with positive health outcomes, whereas job demands are associated with negative health outcomes, among nursing professionals. Strengthening job resources among nursing professionals in the private and public healthcare sectors can promote and sustain their work-related health.

Fifteen years with patient choice and free establishment in Swedish primary healthcare: what do we know?

Background:

In 2007, a reform of Swedish primary healthcare began when some regions implemented enhanced patient choice in combination with free establishment for private providers. Although heavily debated, in 2010 it became mandatory for all regions to implement this choice system.

Aim:

The aim of this article was to review all published research articles related to the primary healthcare choice reform in Sweden, to investigate what has been published about the reform and summarise its first 15 years.

Methods:

A scoping review was performed to cover the breadth of research on the reform. Searches were made in Scopus, Web of Science and PubMed for articles published between 2007 and 2021, resulting in 217 unique articles. In total, 52 articles were included.

Results:

The articles were summarised and presented in relation to six overarching themes: arguments about the primary healthcare choice reform; governance and financial reimbursements; choice of provider and use of information; effects on equity and access; effects on quality; and differences between private and public primary healthcare centres.

Conclusions:

The articles show that the reform has led to an increase in access to primary healthcare, but most studies indicate that the increase is inequitably distributed in terms of socioeconomy and geographical location. The effects on quality are unclear but several studies show that the mechanisms supposed to lead to quality improvements do not work as intended. Furthermore, from a population health perspective, it is time to discuss how such a responsibility can be reintegrated into primary healthcare and function with the choice system.

Health system reforms and the needs of the ageing population—an analysis of recent policy paths and reform trends in Finland and Sweden

Population ageing with an increasing number of people experiencing complex health and social care needs challenges health systems. We explore whether and how health system reforms and policy measures adopted during the past two decades in Finland and Sweden reflect and address the needs of the older people. We discuss health system characteristics that are important to meet the care needs of older people and analyse how health policy agendas have highlighted these aspects in Finland and Sweden. The analysis is based on “most similar cases”. The two countries have rather similar health systems and are facing similar challenges. However, the policy paths to address these challenges are different. The Swedish health system is better resourced, and the affordability of care better ensured, but choice and market-oriented competition reforms do not address the needs of the people with complex health and social care needs, rather it has led to increased fragmentation. In Finland, the level of public funding is lower which may have negative impacts on people who need multiple services. However, in terms of integration and care coordination, Finland seems to follow a path which may pave the way for improved coordination of care for people with multiple care needs. Intensified monitoring and analysis of patterns of health care utilization among older people are warranted in both countries to ensure that care is provided equitably.

Weak association between socioeconomic Care Need Index and primary care visits per registered patient in three Swedish regions

OBJECTIVE

The objective was to examine the association between primary care consultations and a Care Need Index (CNI) used to compensate Swedish primary care practices for the extra workload associated with patients with low socioeconomic status.

DESIGN

Observational study combining graphical analysis with linear regressions of cross-sectional administrative practice-level data.

SETTING

Three Swedish regions, Västra Götaland, Skåne and Östergötland (3.5 million residents). Outcomes were measured in February 2018 and the CNI was computed based on data for 31 December 2017.

SUBJECTS

The unit of analysis was the primary care practice (n = 390).

MAIN OUTCOME MEASURES

i) Number of GP visits per registered patient; ii) Number of nurse visits per registered patient; iii) Number of morbidity-weighted GP visits per registered patient; iv) Number of morbidity-weighted nurse visits per registered patient.

RESULTS

The linear associations between the CNI and GP visits per patient were positive and statistically significant (p<0.01) for both the unweighted and weighted measure in two regions, but the associations were mainly due to 10 practices with very high CNI values. The results for nurse visits varied across regions.

CONCLUSIONS

For most levels of the CNI, there was no association with the number of consultations provided. This result may indicate insufficient compensation, weak incentives to spend the money, decisions to spend the money on other things than consultations, or stronger competition for patients among low-CNI practices. The result of this observational study should not be taken as evidence against the possibility that the CNI adjustment of capitation may have affected the socioeconomic equity in GP and nurse visits.Key PointsSwedish primary care practices receive extra compensation for socioeconomically deprived patients but it is unknown how this affects service provision.Practice-level data from three regions years 2017-2018 indicate weak or no relation between the socioeconomic burden and the number of physical consultations per patient.Results are similar when adjusting for patients' morbidity levels, suggesting that the weak gradient was not explained by longer consultations.The exception is that a small number of practices with very high burdens provide more consultations per patient.The results may reflect insufficient compensation, lack of incentives, or funds being spent on other things than consultations.

Impact of Integrated Care on the Rate of Hospitalization for Ambulatory Care Sensitive Conditions among Older Adults in Stockholm County: An Interrupted Time Series Analysis

Introduction:

Reducing avoidable hospital admissions is often viewed as a possible positive consequence of introducing integrated care (IC). The aim of this study was to investigate the impact of implementing IC in Norrtälje on the rate of admissions for ambulatory care sensitive conditions (ACSC).

Method:

Using interrupted time series analyses we investigated the effect of implementing IC in Norrtälje municipality in the northern part of Stockholm county, Sweden. The time period included 48 time points, from year 2000 to year 2011 with measurements before and after introducing IC in Norrtälje in 2006. In order to control for other extraneous events that could affect the outcome measure, but not related to the introduction of IC, we included a control population from Stockholm municipality.

Results:

After introducing IC in Norrtälje the rate of admissions for ACSC decreased. This decrease was greater in Norrtälje than in the matched control population, however the difference between the two areas was not statistically significant (p = 0.08).

Conclusion:

Introducing IC in Norrtälje may have had positive impact on admissions for ACSC for older people living in Norrtälje; however, the interpretation of the impact of IC on admissions for ACSC is complicated by intervening policy changes in health and social care during the study period.

How do people choose to be informed? A survey of the information searched for in the choice of primary care provider in Sweden

Background

To stimulate quality through choice of provider, patients need to seek and base their decisions on both relevant and reliable information describing providers’ clinical quality. The purpose of this study was first to investigate what types of information and information sources patients turned to in the active choice of primary care provider. Second, it investigated whether a sub-group of patients considered more likely to actively seek information, also sought more advanced information about the clinical quality of providers.

Methods

Data collection was performed through a web-based survey to the general adult (18+) Swedish population, for a net sample of 3150 respondents. Descriptive statistics were used to study what types of information and information sources respondents used prior to their choice. Multiple regression analysis was employed to examine predictors for seeking relevant and reliable information describing providers’ clinical quality.

Results

Patients in active choice situations searched for a median of four information types and used a median of one information source. The information searched for was primarily basic information, for instance, how to switch providers and their geographical location. Information sources used were mainly partisan sources, such as providers themselves, and family and acquaintances. The sub-group of individuals more likely to seek information were not found to seek more advanced forms of information.

Conclusions

Not even the patients considered most likely to seek information prior to their choice of primary care provider, searched for information deemed necessary to make well-informed choices. Thus, patients did not act according to the theoretical assumptions underlying the patient choice reforms, i.e., making informed choices based on clinical quality in order to promote the best providers over inferior ones. The results call for governments and health care authorities to actively assess and develop primary care providers’ clinical quality by means other than patient choice.

Performing Through Privatization: An Ecological Natural Experiment of the Impact of the Swedish Free Choice Reform on Ambulatory Care Sensitive Conditions

Background: In 2010, Sweden opened up for establishment of privately owned primary health care providers, as part of a national Free Choice in Primary Health Care reform. The reform has been highly debated, and evidence on its effects is scarce. The present study therefore sought to evaluate whether the reform have impacted on primary health care service performance. Methods: This ecological register-based study used a natural experimental approach through an interrupted time series design. Data comprised the total adult population of the 21 counties of Sweden 2001-2009 (pre-intervention period) and 2010-2016 (post-intervention period). Hospitalizations and emergency department visits for ambulatory care sensitive conditions (ACSC) were used as indicators of primary health care performance. Segmented regression analysis was used to assess the effects of the reform, in Sweden as a whole, as well as compared between counties grouped by (i) change in private provision pre- to post reform; (ii) the timing of the implementation; and (iii) sustained presence of private providers both pre- and post-reform. Results: The results suggest that, following the introduction of the reform in Sweden as a whole, the trends in total hospitalizations rates were slowed down by 1.0% albeit acute emergency visits increased 1.1% more rapidly after the introduction of the reform. However, we found no evidence of more beneficial effects in counties where the reform had been implemented more ambitiously, specifically those with a larger increase in private primary care providers, or where the reform was introduced early and thus had longer time effects to emerge. Lastly, counties with a sustained high presence of private primary care providers displayed the least favorable development when it comes to ACSC. Conclusion: Taken together, the present study does not support that the Swedish Free Choice reform has improved performance of the primary care delivery system in Sweden, and suggests that high degree of private provision may involve worse performance and higher care burden for specialized health care. Further evaluations of the consequences of the reform are dire needed to provide a comprehensive picture of its intended and unintended impact on health care provision, delivery and results.

Preserving social equity in marketized primary care: strategies in Sweden

A primary care choice reform launched in Sweden in 2010 led to a rapid growth of private providers. Critics feared that the reform would lead to an increased tendency among new, profit-driven, providers, to select patients with lower health risks. Even if open risk selection is prohibited, providers can select patients in more subtle ways, such as establishing their practices in areas with higher health status. This paper investigates to what extent strategies were employed by local governments to avoid risk selection and whether there were any differences between left- and right-wing governments in this regard. Three main strategies were used: risk adjustment of the financial reimbursements on the basis of health and/or socio-economic status of listed patients; design of patient listing systems; and regulatory requirements regarding the scope and content of the services that had to be offered by all providers. Additionally, left-wing local governments were more prone than right-wing governments to adopt risk adjustment strategies at the onset of the reform but these differences diminished over time. The findings of the paper contribute to our understanding of how social inequalities may be avoided in tax-based health care systems when market-like steering models such as patient choice are introduced.

Predicting GP visits: A multinomial logistic regression investigating GP visits amongst a cohort of UK patients living with Myalgic encephalomyelitis

Background

Myalgic Encephalomyelitis (ME) is a chronic condition whose status within medicine is the subject of on-going debate. Some medical professionals regard it as a contentious illness. Others report a lack of confidence with diagnosis and management of the condition. The genesis of this paper was a complaint, made by an ME patient, about their treatment by a general practitioner. In response to the complaint, Healthwatch Trafford ran a patient experience-gathering project.

Method

Data was collected from 476 participants (411 women and 65 men), living with ME from across the UK. Multinomial logistic regression investigated the predictive utility of length of time with ME; geographic location (i.e. Manchester vs. rest of UK); trust in GP; whether the patient had received a formal diagnosis; time taken to diagnosis; and gender. The outcome variable was number of GP visits per year.

Results

All variables, with the exception of whether the patient had received a formal diagnosis, were significant predictors.

Conclusions

Relationships between ME patients and their GPs are discussed and argued to be key to the effective delivery of care to this patient cohort. Identifying potential barriers to doctor patient interactions in the context of ME is crucial.

Digital Divide in Perceived Benefits of Online Health Care and Social Welfare Services: National Cross-Sectional Survey Study

Background

The number of online services in health care is increasing rapidly in developed countries. Users are expected to take a more skilled and active role in taking care of their health and prevention of ill health. This induces risks that users (especially those who need the services the most) will drop out of digital services, resulting in a digital divide or exclusion. To ensure wide and equal use of online services, all users must experience them as beneficial.

Objective

This study aimed to examine associations of (1) demographics (age, gender, and degree of urbanization), (2) self-rated health, (3) socioeconomic position (education, experienced financial hardship, labor market position, and living alone), (4) social participation (voting, satisfaction with relationships, and keeping in touch with friends and family members), and (5) access, skills, and extent of use of information and communication technologies (ICT) with perceived benefits of online health care and social welfare services. Associations were examined separately for perceived health, economic, and collaboration benefits.

Methods

We used a large random sample representative of the Finnish population including 4495 (56.77% women) respondents aged between 20 and 97 years. Analyses of covariance were used to examine the associations of independent variables with perceived benefits.

Results

Access to online services, ICT skills, and extent of use were associated with all examined benefits of online services. ICT skills seemed to be the most important factor. Poor self-rated health was also consistently associated with lower levels of perceived benefits. Similarly, those who were keeping in touch with their friends and relatives at least once a week perceived online services more often beneficial in all the examined dimensions. Those who had experienced financial hardship perceived fewer health and economic benefits than others. Those who were satisfied with their relationships reported higher levels of health and collaboration benefits compared with their counterparts. Also age, education, and degree of urbanization had some statistically significant associations with benefits but they seemed to be at least partly explained by differences in access, skills, and extent of use of online services.

Conclusions

According to our results, providing health care services online has the potential to reinforce existing social and health inequalities. Our findings suggest that access to online services, skills to use them, and extent of use play crucial roles in perceiving them as beneficial. Moreover, there is a risk of digital exclusion among those who are socioeconomically disadvantaged, in poor health, or socially isolated. In times when health and social services are increasingly offered online, this digital divide may predispose people with high needs for services to exclusion from them.

Structuring Sustainable Universal Health Care in South Africa

Intervening in debates around universal health care in South Africa, this article draws on class-based analytical tools from social medicine, political economy, and historical sociology. It is argued there are 3 keys to achieving sustainable universal health care in South Africa: addressing the socioeconomic roots of ill health; establishing a fully public, nonprofit health care system; and adequate investment in undervalued female workers who are the backbone of public health care. Each key is discussed with accompanying recommendations, using evidence from South Africa and other countries. Principal constraints are also identified through an analysis demonstrating the links between inequality, health care financing, and the monopoly structure of the South African health care industry.

Diversity as salvation? - A comparison of the diversity rationale in the Swedish pharmacy ownership liberalization reform and the primary care choice reform

Widespread liberalizing reform of the Swedish community pharmacy and primary care sectors took place in 2009-2010, including opening the market to private providers. One important rationale for the reforms was to increase diversity in the health-care system by providing more choices for individuals. The aim of this study was to increase the understanding how policy makers understood and defined diversity as a concept, and as a rationale for the reforms. The method used was document analysis of preparatory work and plenary parliament debate protocols. The results show that policy makers held vague and unclear definitions of diversity, which complicated its implementation. Diversity was sometimes seen as an effect of competition-a goal-while in other cases it was seen as a condition to be met in order to achieve competition-a means. Thus, policy makers viewed diversity both as a goal and as a means, making the underlying mechanisms unclear. The findings also revealed that policy makers failed to consistently demonstrate how the introduction of competition would lead to diversity.

Primary care doctor fostering and clinical research training in Sweden: Implications for Japan

In 2018, a new training program for primary care physicians was launched in Japan. As physicians responsible for the training of new primary care physicians, we have faced many problems, particularly in rural areas. The influence of this new program on primary care physicians in rural areas of Japan has not been sufficiently investigated. The aim of this research was to improve training for primary care physicians in Japan by examining training programs in Sweden, where the population challenges are similar to those seen in Japan. In this paper, we will express our opinions and describe the differences in the primary care fostering systems and clinical research training for generalist in Japan and Sweden.

Risk selection in primary care: a cross-sectional fixed effect analysis of Swedish individual data

OBJECTIVE

To assess socioeconomic differences between patients registered with private and public primary healthcare centres.

DESIGN

Population-based cross-sectional study controlling for municipality and household.

SETTING

Swedish population-based socioeconomic data collected from Statistics Sweden linked with individual registration data from all 21 Swedish regions.

PARTICIPANTS

All individuals residing in Sweden on 31 December 2015 (n=9 851 017) were included in the study.

PRIMARY OUTCOME MEASURES

Registration with private versus public primary healthcare centres.

RESULTS

After controlling for municipality and household, individuals with higher socioeconomic status were more likely to be registered with a private primary healthcare provider. Individuals in the highest income quantile were 4.9 percentage points (13.7%) more likely to be registered with a private primary healthcare provider compared with individuals in the lowest income quantile. Individuals with 1-3 years of higher education were 4.7 percentage points more likely to be registered with a private primary healthcare provider compared with those with an incomplete primary education.

CONCLUSIONS

The results show that there are notable differences in registration patterns, indicating a skewed distribution of patients and health risks between private and public primary healthcare providers. This suggests that risk selection behaviour occurs in the reformed Swedish primary healthcare system, foremost through location patterns.

Market-orienting reforms in rural health care in Sweden: how can equity in access be preserved?

BACKGROUND

Health care provision in rural and urban areas faces different challenges. In Sweden, health care provision has been predominantly public and equitable access to care has been pursued mainly through public planning and coordination. This is to ensure that health needs are met in the same manner in all parts of the country, including rural or less affluent areas. However, a marketization of the health care system has taken place during recent decades and the publicly planned system has been partially replaced by a new market logic, where private providers guided by financial concerns can decide independently where to establish their practices. In this paper, we explore the effects of marketization policies on rural health care provision by asking how policy makers in rural counties have managed to combine two seemingly contradictory health policy goals: to create conditions for market competition among health care providers and to ensure equal access to health care for all patients, including those living in rural and remote areas.

METHODS

A qualitative case study within three counties in the northern part of Sweden, characterized by vast rural areas, was carried out. Legal documents, the "accreditation documents" regulating the health care quasi-markets in the three counties were analyzed. In addition, interviews with policy makers in the three county councils, representing the political majority, the opposition, and the political administration were conducted in April and May 2013.

RESULTS

The findings demonstrate the difficulties involved in introducing market dynamics in health care provision in rural areas, as these reforms not only undermined existing resource allocation systems based on health needs but also undercut attempts by local policy makers to arrange for care provision in remote locations through planning and coordination.

CONCLUSION

Provision of health care in rural areas is not well suited for market reforms introducing competition, as this may undermine the goal of equity in access to health care, even in a publicly financed health care system.

Primary care workforce development in Europe: An overview of health system responses and stakeholder views

Better primary care has become a key strategy for reforming health systems to respond effectively to increases in non-communicable diseases and changing population needs, yet the primary care workforce has received very little attention. This article aligns primary care policy and workforce development in European countries. The aim is to provide a comparative overview of the governance of workforce innovation and the views of the main stakeholders. Cross-country comparisons and an explorative case study design are applied. We combine material from different European projects to analyse health system responses to changing primary care workforce needs, transformations in the general practitioner workforce and patient views on workforce changes. The results reveal a lack of alignment between primary care reform policies and workforce policies and high variation in the governance of primary care workforce innovation. Transformations in the general practitioner workforce only partly follow changing population needs; countries vary considerably in supporting and achieving the goals of integration and community orientation. Yet patients who have experienced task shifting in their care express overall positive views on new models. In conclusion, synthesising available evidence from different projects contributes new knowledge on policy levers and reveals an urgent need for health system leadership in developing an integrated people-centred primary care workforce.

When do people choose to be informed? Predictors of information-seeking in the choice of primary care provider in Sweden

Improving the ability of patients to make informed choices of health care provider can give providers more incentive to compete based on quality. Still, it is not evident to what extent and when people search for information when choosing a provider. The aim of this study is to identify under what circumstances individuals seek information when choosing a primary care provider. Research to date has mostly focused on individuals' demographic and socio-economic characteristics and the poor availability of information as barriers to information-seeking and use. Our results highlight the importance of taking individuals' personal motivations and situational context into account when studying information-seeking behavior. Overall, these results suggest that not even individuals who are likely to search for information since they switched or considered switching primary care provider, do so to any greater extent. However, those motivated to change providers by internal factors such as dissatisfaction or a belief that other providers may provide superior services actively sought out information to a greater extent than those motivated by external factors such as the closure of their current provider, or by moving house. Gender, employment status, place of residence and education level was also significantly associated with information-seeking.

Does risk-adjusted payment influence primary care providers' decision on where to set up practices?

Background

Providing equal access to health care is an important objective in most health care systems. It is especially pertinent in systems like the Swedish primary care market, where private providers are free to establish themselves in any part of the country. To improve equity in access to care, 15 out 21 county councils in Sweden have implemented risk-adjusted capitation based on the Care Need Index, which increases capitation to primary care centers with a large share of patients with unfavorable socioeconomic and demographic characteristics. Our aim is to estimate the effects of using care-need adjusted capitation on the supply of private primary care centers.

Method

We use a dataset that combines information on all primary care centers in Sweden during 2005–2013, the payment system and other conditions for establishing new primary care centers used in the county councils, and demographic, geographic, and socioeconomic variables for low-level geographic areas. To estimate the effects of care-need adjusted capitation, we use difference-in-differences models, contrasting the development over time between areas with and without risk-adjusted capitation, and with high and low Care Need Index values.

Results

Risk-adjusted capitation significantly increases the number of private primary care centers in areas with relatively high Care Need Index values. The adjustment results in a changed distribution of private centers within county councils; the total number of private centers does not increase in county councils using care-need adjusted capitation. The effects are furthermore increasing over the first three years after the implementation of such capitation, and concentrated to the lower and middle range of the group of areas with high index values.

Conclusions

Risk-adjusted capitation based on the Care Need Index increases the supply of private primary care centers in areas with unfavorable socioeconomic and demographic characteristics. More generally, this result indicates that risk-adjusted capitation can significantly affect private providers’ establishment decisions.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2983-3) contains supplementary material, which is available to authorized users.

The National Health Services of Brazil and Northern Europe: Universality, Equity, and Integrality-Time Has Come for the Latter

In 1990 the national health services in the United Kingdom and Sweden started to split up in internal markets with purchasers and providers. It was also the year when Brazil started to implement a national health service (SUS) inspired by the British national health service that aimed at principles of universality, equity, and integrality. While the reform in Brazil aimed at improving equity and effectiveness, reforms in Europe aimed at improving efficiency in order to contain costs. The European reforms increased supply and utilization but never provided the large increase in efficiency that was hoped for, and inequities have increased. The health sector reform in Brazil, on the other hand, contributed to great improvements in population health but never succeeded in changing the fact that more than half of health care spending was private. Demographic and epidemiological changes, with more elderly people having chronic disorders and very unequal comorbidities, bring the issue of integrality in the forefront in all 3 countries, and neither the public purchaser provider markets nor the 2-tier system in Brazil delivers on that front. It will demand political leadership and strategic planning with population responsibility to deal with such challenges.

What patients think about choice in healthcare? A study on primary care services in Finland

BACKGROUND

The ongoing Finnish health and social service reform will expand choice by opening the market for competition between public and private service providers. This study examined the attitudes of primary care patients towards choice and which patient-related factors are associated with these attitudes.

METHODS

A sample of attenders during one week in health centres of 12 big cities and municipal consortiums (including seven outsourced local units) and in primary care units of one private company providing outsourced services for municipalities (aged 18-95, n=8128) was used. The questionnaire included questions on choice-related attitudes, sociodemographic factors, health status, use of health services and patient satisfaction.

RESULTS

Of the responders, 77% regarded choice to be important, 49% perceived genuine opportunities to make choices and 35% were satisfied with the choice-relevant information. Higher age, low education, having a chronic illness, frequent use of services, having a personal physician and being satisfied with the physician and with waiting times were related to assigning more importance on choice. Younger patients, those with higher education as well as those with chronic illness regarded their opportunities of choosing the service provider and availability of choice-relevant information poorer.

CONCLUSIONS

The Finnish primary care patients value choice, but they are critical of the availability of choice-relevant information. Choices of patients with complex health care needs should be supported by developing integrated care alternatives and by increasing the availability of information on existing care alternatives to meet their needs.

Equity aspects of the Primary Health Care Choice Reform in Sweden - a scoping review

Background

Good health and equal health care are the cornerstones of the Swedish Health and Medical Service Act. Recent studies show that the average level of health, measured as longevity, improves in Sweden, however, social inequalities in health remain a major issue. An important issue is how health care services can contribute to reducing inequalities in health, and the impact of a recent Primary Health Care (PHC) Choice Reform in this respect. This paper presents the findings of a review of the existing evidence on impacts of these reforms.

Methods

We reviewed the published accounts (reports and scientific articles) which reported on the impact of the Swedish PHC Choice Reform of 2010 and changes in reimbursement systems, using Donabedian’s framework for assessing quality of care in terms of structure, process and outcomes.

Results

Since 2010, over 270 new private PHC practices operating for profit have been established throughout the country. One study found that the new establishments had primarily located in the largest cities and urban areas, in socioeconomically more advantaged populations. Another study, adjusting for socioeconomic composition found minor differences. The number of visits to PHC doctors has increased, more so among those with lesser needs of health care. The reform has had a negative impact on the provision of services for persons with complex needs. Opinions of doctors and staff in PHC are mixed, many state that persons with lesser needs are prioritized. Patient satisfaction is largely unchanged. The impact of PHC on population health may be reduced.

Conclusions

The PHC Choice Reform increased the average number of visits, but particularly among those in more affluent groups and with lower health care needs, and has made integrated care for those with complex needs more difficult. Resource allocation to PHC has become more dependent on provider location, patient choice and demand, and less on need of care. On the available evidence, the PHC Choice Reform may have damaged equity of primary health care provision, contrary to the tenets of the Swedish Health and Medical Service Act. This situation needs to be carefully monitored.

Referring to multimodal rehabilitation for patients with musculoskeletal disorders - a register study in primary health care

Background

In 2008, the Swedish government introduced a National Rehabilitation Program, in which the government financially reimburses the county councils for evidence-based multimodal rehabilitation (MMR) interventions. The target group is patients of working age with musculoskeletal disorders (MSD), expected to return to work or remain at work after rehabilitation. Much attention in the evaluations has been on patient outcomes and on processes. We lack knowledge about how factors related to health care providers and community can have an impact on how patients have access to MMR. The aim of this study was therefore to study the impact of health care provider and community related factors on referrals to MMR in patients with MSD applying for health care in primary health care.

Methods

This was a primary health care-based cohort study based on prospectively ascertained register data. All primary health care centres (PHCC) contracted in Region Skåne in 2010-2012, referring to MMR were included (n = 153). The health care provider factors studied were: community size, PHCC size, public or private PHCC, whether or not the PHCCs provided their own MMR, burden of illness and the community socioeconomic status among the registered population at the PHCCs. The results are presented with descriptive statistics and for the analysis, non-parametric and multiple linear regression analyses were applied.

Results

PHCCs located in larger communities sent more referrals/1000 registered population (p = 0.020). Private PHCCs sent more referrals/1000 registered population compared to public units (p = 0.035). Factors related to more MMR referrals/1000 registered population in the multiple regression analyses were PHCCs located in medium and large communities and with above average socioeconomic status among the registered population at the PHCCs, private PHCC and PHCCs providing their own MMR. The explanation degree for the final model was 24.5%.

Conclusions

We found that referral rates to MMR were positively associated with PHCCs located in medium and large sized communities with higher socioeconomic status among the registered population, private PHCCs and PHCCs providing their own MMR. Patients with MSD are thus facing significant inequities and were thus not offered the same opportunities for referrals to rehabilitation regardless of which PHCC they visited.

Risks and Opportunities of Reforms Putting Primary Care in the Driver's Seat Comment on "Governance, Government, and the Search for New Provider Models"

Recognizing the advantages of primary care as a means of improving the entire health system, this text comments on reforms of publicly funded primary health centers, and the rapid development of private for-profit providers in Sweden. Many goals and expectations are connected to such reforms, which equally require critical analyses of scarce resources, professional trust/motivation and business logic in the wake of freedom and control of ownership and management. In line with Saltman and Duran, this article calls for research and a methodologically developed approach to capture everyday practice in-depth and how regulation, market incentives and patient demands are met by professionals and primary care leaders.