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The geographical accessibility of health services is an important issue especially in developing countries and even more for those sharing a border as for Haiti and the Dominican Republic. During the last 2 decades, numerous studies have explored the potential spatial access to health services within a whole country or metropolitan area. However, the impacts of the border on the access to health resources between two countries have been less explored. The aim of this paper is to measure the impact of the border on the accessibility to health services for Haitian people living close to the Haitian-Dominican border. To do this, the widely employed enhanced two-step floating catchment area (E2SFCA) method is applied. Four scenarios simulate different levels of openness of the border. Statistical analysis are conducted to assess the differences and variation in the E2SFCA results. A linear regression model is also used to predict the accessibility to health care services according to the mentioned scenarios. The results show that the health professional-to-population accessibility ratio is higher for the Haitian side when the border is open than when it is closed, suggesting an important border impact on Haitians' access to health care resources. On the other hand, when the border is closed, the potential accessibility for health services is higher for the Dominicans. The openness of the border has a great impact on the spatial accessibility to health care for the population living next to the border and those living nearby a road network in good conditions. Those findings therefore point to the need for effective and efficient trans-border cooperation between health authorities and health facilities. Future research is necessary to explore the determinants of cross-border health care and offers an insight on the spatial revealed access which could lead to a better understanding of the patients' behavior.

Background Health systems must deliver care equitably in order to serve the poor. Both L’Hôpital Albert Schweitzer (HAS) and L’Hôpital Bon Sauveur (HBS) have longstanding commitments to provide equitable surgical care in rural Haiti. HAS charges fees that demonstrate a preference for the rural population near the hospital, with free care available for the poorest. HBS does not charge fees. The two hospitals are otherwise similar in surgical capacity and rural location. Methods We retrospectively reviewed operative case-logs at both hospitals from June 1 to Aug 31, 2012. The records were compared by total number of operations, geographic distribution of patients and number of elective operations. Using geography as a proxy for poverty, we analyzed the equity achieved under the financial systems at both hospitals. Results Patients from the rural service area received 86 % of operations at HAS compared to 38 % at HBS ( p  < 0.001). Only 5 % of all operations at HAS were performed on patients from outside the service area for elective conditions compared to 47 % at HBS ( p  < 0.001). Within its rural service area, HAS performed fewer operations on patients from the most destitute areas compared to other locations (40.3 vs. 101.3 operations/100,000 population, p  < 0.001). Conclusions Using fees as part of an equity strategy will likely disadvantage the poorest patients, while providing care without fees may encourage patients to travel from urban areas that contain other hospitals. Health systems striving to serve the poor should continually evaluate and seek to improve equity, even within systems that provide free care.

Introduction The aim of this study was to assess how the caseload and the utilisation of community-based mental health services is influenced by distance and to socioeconomic characteristics. Methods Spatial and statistical analyses were conducted with a sample of 12,347 patients, with ICD-10 psychiatric diagnosis, who had at least one contact with psychiatric services in Verona, Italy, between 2000 and 2006. Three types of mental health facility were considered: acute inpatient wards, outpatient clinics, and community mental health centres (CMHC). To measure distance and accessibility, the locations of static mental health facilities and patients’ homes were geocoded. Data were organised in a spatial database, which included census blocks, catchment areas locations, road network graphs, patients’ and facilities’ locations. In order to calculate travel distances, patients’ and facilities’ locations were connected to the road network. Accessibility was modelled by using the Network Analyst Service Area Function and 13 Service Areas were created around all facility locations, by measuring distances along the street network. For the epidemiological analyses, patients and census block centroids were linked to the service areas by using spatial join techniques. Epidemiological and utilisation analyses were performed for each type of setting. Results The facilities were not equally located in the catchment areas. Of particular significance, rural areas appear to be poorly served by mental health services. The distance decay effect exists, with different trends for the three types of facility. The caseload (number of patients using services) decreased with increasing distance; at a distance of 10 km, there was a decrease of 80, 60 and 85%, respectively, for CMHCs, inpatients wards and outpatients clinics. From the Poisson regression models, distance was significantly correlated ( p value < 0.0001) with service use. Also univariate analyses showed a statistically significant association between distance and caseload for each type of setting ( p value < 0.05), with a decrease in service use for each service area increase in distance (1.5% for acute inpatient wards, 2.0% for CMHC, and 2.1% outpatient clinics). By adding other predictors in the Poisson regression models, these percentages increased. Conclusions Further studies are needed to evaluate the influence of other factors, such as environmental variables, that may influence the use of mental health services.

The long-term trend of consolidation among US health plans has raised providers' concerns that the concentration of health plan markets can depress their prices. Although our study confirmed that, it also revealed a more complex picture. First, we found that 64 percent of hospitals operate in markets where health plans are not very concentrated, and only 7 percent are in markets that are dominated by a few health plans. Second, we found that in most markets, hospital market concentration exceeds health plan concentration. Third, our study confirmed earlier studies showing that greater hospital market concentration leads to higher hospital prices. Fourth, we found that hospital prices in the most concentrated health plan markets are approximately 12 percent lower than in more competitive health plan markets. Overall, our results show that more concentrated health plan markets can counteract the price-increasing effects of concentrated hospital markets, and that-contrary to conventional wisdom-increased health plan concentration benefits consumers through lower hospital prices as long as health plan markets remain competitive. Our findings also suggest that consumers would benefit from policies that maintained competition in hospital markets or that would restore competition to hospital markets that are uncompetitive. [PUBLICATION ABSTRACT]

The emphasis that hospitals place on cutting-edge technology and niche specialty services to attract physicians and patients has set the stage for health care's most recent competitive trend: an increased level of targeted, geographic service expansion to \"capture\" well-insured patients. We conducted interviews in twelve US communities in 2010 and found that many hospital systems-some with facilities in geographically undesirable areas-have expanded to compete for better-insured patients by building or buying facilities and physician practices in nearby, more affluent communities. Along with extending services to new markets, these hospital outposts often serve to pull well-insured patients to flagship facilities. The acceleration and expansion of such geographically competitive strategies by hospitals has implications for cost and access. Although payers and competitors contend such strategies will lead to higher costs, hospitals assert the expansions will increase efficiency, increase access, and improve the quality of care provided to patients. [PUBLICATION ABSTRACT]

Proposals to move toward reducing geographic differentials in health care spending have focused on patterns of spending in Medicare. We show in this article that when considering each state as a whole, there is almost no relationship between the level of spending for Medicare beneficiaries and that for other populations. In sharp contrast to these state-level results, there is a strong relationship between Medicare and Medicaid spending in comparing Hospital Referral Regions within each state. We suggest that the strong intrastate regional correlations demonstrate the importance of the supply of hospital beds, specialists, and other health care resources as determinants of use and spending. In contrast, the lack of correlation at the state level suggests that other factors, such as state-level poverty rates, influence use and spending at the state level, and that these other factors influence Medicare and non-Medicare use and spending differently. These findings demonstrate that it is important to broaden our analytic focus from Medicare beneficiaries to the larger population, and to consider the likely effects of changes in Medicare payment policy on the care received by other state residents. [PUBLICATION ABSTRACT]

This paper reports on a qualitative study of lay knowledge about health inequalities and solutions to address them. Social determinants of health are responsible for a large proportion of health inequalities (unequal levels of health status) and inequities (unfair access to health services and resources) within and between countries. Despite an expanding evidence base supporting action on social determinants, understanding of the impact of these determinants is not widespread and political will appears to be lacking. A small but growing body of research has explored how ordinary people theorise health inequalities and the implications for taking action. The findings are variable, however, in terms of an emphasis on structure versus individual agency and the relationship between being 'at risk' and acceptance of social/structural explanations. This paper draws on findings from a qualitative study conducted in Adelaide, South Australia, to examine these questions. The study was an integral part of mixed-methods research on the links between urban location, social capital and health. It comprised 80 in-depth interviews with residents in four locations with contrasting socio-economic status. The respondents were asked about the cause of inequalities and actions that could be taken by governments to address them. Although generally willing to discuss health inequalities, many study participants tended to explain the latter in terms of individual behaviours and attitudes rather than social/structural conditions. Moreover, those who identified social/structural causes tended to emphasise individualized factors when describing typical pathways to health outcomes. This pattern appeared largely independent of participants' own experience of advantage or disadvantage, and was reinforced in discussion of strategies to address health inequalities. Despite the explicit emphasis on social/structural issues expressed in the study focus and framing of the research questions, participants did not display a high level of knowledge about the nature and causes of place-based health inequalities. By extending the scope of lay theorizing to include a focus on solutions, this study offers additional insights for public health. Specifically it suggests that a popular constituency for action on the social determinants of health is unlikely to eventuate from the current popular understandings of possible policy levers.

Whether activity-based financing of hospitals creates incentives to treat more patients and to reduce the length of each hospital stay is an empirical question that needs investigation. This paper examines how the level of the activity-based component in the financing system of Norwegian hospitals influences the average length of hospital stays for elderly patients suffering from ischemic heart diseases. During the study period, the activity-based component changed several times due to political decisions at the national level. The repeated cross-section data were extracted from the Norwegian Patient Register in the period from 2000 to 2007, and included patients with angina pectoris, congestive heart failure, and myocardial infarction. Data were analysed with a log-linear regression model at the individual level. The results show a significant, negative association between the level of activity-based financing and length of hospital stays for elderly patients who were suffering from ischemic heart diseases. The effect is small, but an increase of 10 percentage points in the activity-based component reduced the average length of each hospital stay by 1.28%. In a combined financing system such as the one prevailing in Norway, hospitals appear to respond to economic incentives, but the effect of their responses on inpatient cost is relatively meagre. Our results indicate that hospitals still need to discuss guidelines for reducing hospitalisation costs and for increasing hospital activity in terms of number of patients and efficiency.

Background: Improving access to optimal healthcare may depend on the attributes of neighborhoods where patients receive healthcare services. We investigated whether the characteristics of dialysis facility neighborhoods - where most patients with end-stage renal disease are treated - were associated with facility-level kidney transplantation. Methods: We examined the association between census tract (neighborhood)-level sociodemographic factors and facility-level kidney transplantation rate in 3,983 U.S. dialysis facilities where kidney transplantation rates were high. Number of kidney transplants and total person-years contributed at the facility level in 2007-2010 were obtained from the Dialysis Facility Report and linked to the census tract data on sociodemographic characteristics from the American Community Survey 2006-2010 by dialysis facility location. We used multivariable Poisson models with generalized estimating equations to estimate the link between the neighborhood characteristics and transplant incidence. Results: Dialysis facilities in the United States were located in neighborhoods with substantially greater proportions of black and poor residents, relative to the national average. Most facility neighborhood characteristics were associated with transplant, with incidence rate ratios (95% CI) for standardized increments (in percentage) of neighborhood exposures of: living in poverty, 0.88 (0.84-0.92), black race, 0.83 (0.78-0.89); high school graduates, 1.22 (1.17-1.26); and unemployed, 0.90 (0.85-0.95). Conclusion: Dialysis facility neighborhood characteristics may be modestly associated with facility rates of kidney transplantation. The success of dialysis facility interventions to improve access to kidney transplantation may partially depend on reducing neighborhood-level barriers.

In spite of a detailed and nation-wide legislation frame, there exist large cantonal disparities in consumed quantities of health care services in Switzerland. In this study, the most important factors of influence causing these regional disparities are determined. The findings can also be productive for discussing the containment of health care consumption in other countries. Based on the literature, relevant factors that cause geographic disparities of quantities and costs in western health care systems are identified. Using a selected set of these factors, individual panel econometric models are calculated to explain the variation of the utilization in each of the six largest health care service groups (general practitioners, specialist doctors, hospital inpatient, hospital outpatient, medication, and nursing homes) in Swiss mandatory health insurance (MHI). The main data source is 'Datenpool santésuisse', a database of Swiss health insurers. For all six health care service groups, significant factors influencing the utilization frequency over time and across cantons are found. A greater supply of service providers tends to have strong interrelations with per capita consumption of MHI services. On the demand side, older populations and higher population densities represent the clearest driving factors. Strategies to contain consumption and costs in health care should include several elements. In the federalist Swiss system, the structure of regional health care supply seems to generate significant effects. However, the extent of driving factors on the demand side (e.g., social deprivation) or financing instruments (e.g., high deductibles) should also be considered.