Accessibility to Urgent and Emergency Care Services in Low-Density Territories
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DOI: 10.1590/1413-81232021266.1.40882020 2483 AR Accessibility to urgent and emergency care services TIGO in low-density territories: the case of Baixo Alentejo, Portugal AR Acessibilidade à rede de serviços de urgência em territórios de baixa TICLE densidade: o caso do Baixo Alentejo, Portugal Rita Ferreira (https://orcid.org/0000-0002-7937-9521)1 Nuno Marques da Costa (https://orcid.org/0000-0003-4859-9668)1 Eduarda Marques da Costa (https://orcid.org/0000-0001-5070-3562)1 Abstract Access to health care is a sensitive is- Resumo Em territórios de baixa densidade sue in low population density territories, as these populacional, o acesso aos cuidados de saúde é areas tend to have a lower level of service provi- uma questão delicada, pois essas áreas tendem a sion. One dimension of access is accessibility. This ter um nível mais baixo de prestação de serviços. paper focuses on measuring the accessibility to Uma dimensão do acesso é a medição da acessi- urgent and emergency care services in the Portu- bilidade. Este artigo tem como propósito medir a guese region of Baixo Alentejo, a territory char- acessibilidade aos serviços de urgência e aos meios acterized by low population density. Data for the de emergência médica na região portuguesa do calculation of accessibility is the road network, Baixo Alentejo, território caracterizado por uma and the methodology considers the application baixa densidade populacional. A metodologia of a two-level network analyst method: time-dis- considera o método network analyst aplicado à tance by own mean (car or taxi) to the urgent rede viária, em dois níveis: o cálculo da distân- care services and the time distance to emergency cia-tempo aos serviços de urgência usando modo services as a way to get assistance and to go to ur- próprio (carro ou táxi); e o cálculo da distância- gent care services. While urgent care accessibility tempo recorrendo aos meios de socorro e emergên- meets the requirements stipulated in the Integrat- cia como forma de aceder aos serviços de urgência. ed Medical Emergency System’s current legislative Embora se considere que a acessibilidade às urgên- framework, the simulation of different scenarios cias atende ao atual quadro legislativo do Sistema of potential accessibility shows intra-regional dis- Integrado de Emergência Médica, a simulação parities. Some territories have a low level of ac- de diferentes cenários no Baixo Alentejo mostra a cessibility. Older adults, the poorly educated, and existência de disparidades intra-regionais no que low-income population, also have the lowest levels se refere à acessibilidade aos serviços de urgência. of accessibility, which translates into dually disad- Verifica-se que é a população idosa, de baixa ins- vantageous situation since the potential users of trução e residente em zonas com baixa densidade emergency services are most likely to belong to this populacional quem apresenta menores índices de group of citizens. acessibilidade, o que traduz uma situação du- 1 Instituto de Geografia e Key words Accessibility, Urgent care Services, plamente desvantajosa, uma vez que estes são os Ordenamento do Território (IGOT), Universidade de Emergency Ambulance Service, Low-Density Ar- maiores utilizadores destes serviços. Lisboa. Edifício IGOT, Rua eas Palavras-chave Acessibilidade, Serviços de Ur- Branca Edmée Marques. gência, Meios de emergência, Áreas de baixa den- 1600-276 Lisboa Portugal. [email protected] sidade 2484 et al. Ferreira R Ferreira Introduction man resources, namely doctors and nurses. For those authors, accessibility is the dimension of In the last decades, demographic and economic access that connects location and the geographic trends have favored urbanized territories in det- distribution of services and users. Affordability is riment of rural areas, primarily characterized by related to the organization of the services and us- the lowest population densities, demographic de- ers’ ability to adapt to this organization (comfort cline, and a large share of older adults with limit- in use). Accommodation is based on the relation- ed mobility and low income. The access to health ship between the service’s use and the possibility services in these territories becomes more rele- of paying for that service. Finally, acceptability is vant, as the decline of demand induced a growing related to the trust and satisfaction felt by pro- scarcity of health services, especially the urgent fessionals and users concerning the services12,15,16. and emergency care services. In this context, the Whatever the perspective, there is a consen- studies related to equity in access gains impor- sus that access to health care is regarded as a fun- tance in support of policy recommendations. damental human right and a social goal because The concept of access to health care is a com- all individuals are entitled to health care17 cit. in18, plex process, and for that reason, there are differ- which obliges governments to create conditions ent perspectives on its definition or methods to for their provision. By definition, if access is the be used. Some authors use the term “accessibili- availability of an adequate supply of health care ty”, while others prefer the term “access”. Both re- services and the individual’s opportunity to ob- fer to the way of obtaining health care services1,2. tain health care when it is wanted or needed18, The concept of accessibility refers to the fa- the equity in access is met when health care is ac- cilities at the population’s disposal, their means cessed according to the needs19 cit. in 20. of transport, and the opportunities available to We have been witnessing changes in the mod- them3-5, while other authors6 believe that acces- els of provision of services in the European con- sibility has two components: one corresponds text, showing a decline of the welfare perspective to the location of services and the population in favor of a more economical viewpoint. The (higher for people that live close), and the second health provision models favor privatization and is related to personal mobility, depending on the the efficiency approaches, putting at risk the eq- transportation mode used to reach the service. A uity in access to all territories and social groups. third perspective, accessibility is related to three Frequently, the areas with a higher concentration dimensions: the territory, the population, and of older adults tend to have lower service provi- the services organization7 (p.106). sion levels, while densely urbanized areas tend to Initially, accessibility was related to the idea have a broader set of affordable services. Howev- of proximity and facility of spatial interaction. er, they often face issues of lack of effectiveness, However, as mentioned by several authors8-12, efficiency, or quality21. physical or geographical accessibility alone is in- For the European Union (EU), the concept sufficient to analyze inequalities in a population’s of “Services of General Interest” (SGI) emerges access to several health care services13,14. as an alternative to the traditional definition of In this context, other economic, social, and social services. They are defined as services that environmental factors are mentioned by the var- the Member States public authorities classify as ious authors, which directly or indirectly influ- being of general interest and where the provid- ence the level of achieving health care. Indeed, ers are therefore entrusted with public service or access to health care has been the subject of dis- universal service obligations, specially dedicated cussion since the 1970s, showing an articulated to economic services, which highlights the im- and integrated approach of the several dimen- portance of the population accessing services, sions. At this stage, we could conclude that the fulfilling equity conditions. To this end, the EU concept of access is more comprehensive and defines some conditions. embracing than acessibility6,13. The Lisbon Treaty (EU, 2010, prot.26), ex- A 1981 study defined five dimensions of ac- pressed in the Protocol “On Services of General cess: availability, accessibility, affordability, ac- Interest”, declares in the first article “the essential commodation, and acceptability12. From this per- role and the wide discretion of national, regional spective, the dimension of availability is related and local authorities in providing, commission- to the (quantified) presence or absence of exist- ing and organizing services of general economic ing services, which can be measured by the type interest as closely as possible to the needs of the of equipment(s) and the number of available hu- users” 15, highlighting citizen social rights and the 2485 Ciência & Saúde Coletiva, 26(Supl. 1):2483-2496, 2021 1):2483-2496, 26(Supl. Coletiva, & Saúde Ciência need of territorial balance in the framework of The study area, the NUTS III of Baixo Alente- SGI22. The European orientations for SGI played jo, part of NUTS II Alentejo, is an aging region, an essential role in ensuring the maintenance of classified in European statistical context as a low dynamics in rural and peripheral territories15 population density area (region composed by lo- since the Member States’ public authorities classi- cal administrative units (LAU 1), generally mu- fy these services as being of general interest. These nicipalities, with less than 150 inhabitants/km2 services may be rendered either by the State or the and not located in an urban center25). We should private sector, to ensure that all citizens should bear in mind the relationship between aging and have access to services, regardless of their social an increase in several chronic and incapacitating characteristics or geographical location22,23. pathologies, such as strokes. These assumptions According to the Green Paper on Services of should be considered for health services, structur- General Interest24, the SGI may assert themselves ing, and responsiveness in a low population den- as an essential contribution to mitigating dispar- sity context since the highest number of potential ities between regions and are indispensable for emergency services users is among older citizens.