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 , 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

Ferreira R et al. 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

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. the subsistence of rural or low-density territories and the small, medium-sized cities/villages locat- The urgent care and emergency services ed in rural and peripheral areas. These cities and in mainland Portugal and Baixo Alentejo villages ensure the provision of services to citi- zens of these regions, including the infrastruc- The National Emergency Services Network tures required for investment in the adaptability and the creation of basic emergency units were of people and businesses15. approved, respectively, on November 14, 2001, This paper aims to measure the accessibility and February 7, 2002. Subsequently, Order of emergency services and medical emergency fa- 18.459/2006, of July 30, published in Diário da cilities in the Portuguese region of Baixo Alentejo, República [Official Gazette], nd2 series, no. 176, of a territory characterized by low population den- September 12, amended by Order 24681/2006, of sity and weak economic activity. The methodolo- October 25, and Order 5414/2008, of January 28, gy considers the network analyst method applied defined the characteristics of the Emergency Ser- to the road network at two levels: the calculation vices Network, its levels of responsibility, criteria, of time-distance to emergency services (hospital conditions of access, and location of emergency and other centers) using own mobility mode (car network points. or taxi); the calculation of time-distance using Recently, Order 10319/2014, of August 11, the National Emergency Medical Service (NIME) determined the structure of the Integrated as a way to reach the emergency services. Medical Emergency System (IMES) concerning It is also important to stress that, as referred hospital responsibility and its interface with the in Order 18459/2006, of July 30, an “urgent or pre-hospital services, with the levels of responsi- emergency case consists of a clinical situation bility of the Urgent Care Services (UCS). It also with a sudden onset, with an actual or potential established minimum standards regarding struc- risk of one or more vital functions being com- ture, human resources, criteria, and quality indi- promised or failing”. Thus, accessibility is es- cators, and defined a monitoring and evaluation sential since it is necessary to ensure the fastest process. response of emergency means and emergency Three levels of reception have been defined services’ best response capacity. for urgent care services. According to their de- One question emerges: Is there equal accessi- gree of specificity, they should respond to a given bility to the urgent and emergency care resources population’s urgent care situations, as shown in distributed across the Baixo ? Chart 1. The presen t work is structured in five parts. The National Institute of Medical Emergency The first consists of the theoretical framework (NIME) is the entity in mainland Portugal re- and the definition of the study’s objectives. The sponsible for the coordination and operation second one describes the organization of the ur- of the Integrated Medical Emergency System gent care service and emergency system in Por- (IMES). All urgent care/emergency activities, tugal and, in more detail, in Baixo Alentejo. The including the pre-hospital emergency system, third part contains a description of the method- patient referral, transportation, and hospital re- ology, followed by a presentation of the results ception, fall within the IMES scope. and its discussion in part four. The study ends In short, when the European emergency with a concluding note. number (112) is called, the calls initially answered 2486

Ferreira R et al. Ferreira Chart 1 . Levels of Urgent Care Service in Portugal. 1st Reception Level 2nd Reception Level 3rd Reception Level Basic Urgent Care Service (BUS) Medical-Surgical Urgent care Multipurpose Urgent care Service Service (MSUS) (MUS)

Responding to more uncomplicated It responds to situations requiring Responding to more complex urgent care and emergencies. more differentiated care. Referral situations and having most It assumes the patient’s initial to higher-level services situations hospital valences. Some MUS stabilization for further referral to a that require the support of specific have Trauma Centers designed to more differentiated level of care in medical specialties. accommodate patients with more more complex situations. severe issues. This service should be available, Ranging from 20 to 39 MSUS or Ranging from 10 to 13 MUS or wherever deemed justified, to ensure according to a ratio of 2/3 per according to a ratio of 1 MUS for the access of a given population MUS. It should be located at least each 100 to 750,000 inhabitants. within a maximum period of 60 60 minutes from another MSES or minutes (in the absence of a higher- MSE, except for cases where the level urgent care service). population covered by each hospital exceeds 200,000 inhabitants. Life support ambulance – LSA Emergency medical and Emergency medical and (ambulância de suporte imediato de resuscitation vehicle – EMRS resuscitation vehicle – EMRS vida - SIV) is available. (Viatura Médica de Emergência e (Viatura Médica de Emergência e Reanimação - VMER) is available. Reanimação - VMER) is available. Source: Order 10319/2014, of August 11.

by the Public Security Police are forwarded to the In practice, it corresponds to the creation of Lo- Urgent Patient Orientation Centers in urgent cal Health Units (LHU), public business entities or emergency medical situations. These Urgent providing integrated primary, differentiated, and Patient Orientation Centers perform the screen- continued health care to the population residing ing, counseling, and selection of the service to be in the geographical area they cover31. triggered to relieve the victims. Screening aims to The Local Health Units of Baixo Alentejo determine the appropriate means for each clin- have three urgent care services, two of which are ical situation and determine the type of health integrated into primary health care, referring to unit that will provide the necessary treatment. essential urgent care services ( and This procedure is based on decision algorithms Moura) and a medical-surgical urgent care ser- approved by the Association of Physicians, whose vice, located at the central hospital of José Joa- mission is to give adequate treatment to distress quim Fernandes Hospital. calls based on clinical criteria26. Chart 2 shows Based on NIME’s information, we can con- the Emergency Services that operate from the clude that there are 18 emergency facilities in this road network and their location. area. Of these, 5 Emergency Ambulances (EA) Concerning the case study area, Baixo Alente- are in the reserve centers, 10 Emergency Medical jo NUTS III, we have the Baixo Alentejo Local Ambulance (EMA) in Emergency Medical Cen- Health Unit (Baixo Alentejo LHU), including an ters, 2 Immediate Life Support Ambulance (LSA) area covered by the Alentejo Regional Health Ad- in the Castro Verde and Moura basic urgent care ministration, I.P. (ARS Alentejo). service, and 1 Emergency Medical and Resuscita- Health care integration may be one of two tion Vehicle (EMRS) at the Beja Hospital (Hos- options: vertical integration or horizontal inte- pital with a Medical-Surgical Urgent care Service gration29. In vertical integration, a single entity is - MSUS). responsible for managing the services at the same Concerning the study area, Baixo Alentejo has healthcare level. On the other hand, horizontal a lower population density, and the population integration involves the provision of multi-level variation is negative in all municipalities, except health services, which means that a single entity Beja, which has the highest municipality popula- is responsible for the health status of a given pop- tion density of approximately 31.2 inhabitants/ ulation, including the various types of health care km2. Nevertheless, this figure is considerably low- – primary, hospital, continued, and palliative30. er than the country’s average (114.5 inhabitants/ 2487 Ciência & Saúde Coletiva, 26(Supl. 1):2483-2496, 2021

Chart 2 . Types of Emergency Ambulance Service in Portugal. Emergency Ambulance Service Description Location Emergency ambulance – EA Ensures the rapid response of a team with training Medical (ambulância de Socorro - AS) in emergency techniques to the scene. It acts in emergency conjunction with other pre-hospital services. points Emergency medical Ambulance - Ensures the rapid response of a pre-hospital medical NIME; MSUS; EMA (ambulância de emergência emergency team with training in emergency MUS médica - AEM) techniques to the scene. Immediate life support ambulance – Ensures more differentiated care, such as BUS LSA (ambulância de suporte imediato resuscitation maneuvers in a pre-hospital de vida - SIV) environment. Emergency medical and resuscitation Ensures pre-hospital stabilization and medical MSUS and vehicle - EMRS (Viatura Médica de follow-up during the transportation of accident MUS Emergência e Reanimação - VMER) victims. Source: NIME 26-28.

km2, according to the 2011 Census). In the last 27 (Beja - Castro Marim) and the national road Census, the aging rate registered in Baixo Alente- throughout the territory (besides other low- jo was 188.8%, which shows that this is an aged er-level municipal roads) were also considered territory. The study area population has a high for this calculation. illiteracy rate and an unemployment rate higher After validating the road network and creat- than the national average (13.2% at the national ing the time-distance field, which corresponds level and 14.4% in Baixo Alentejo). to the restriction factor, a network dataset and The urban system of Baixo Alentejo tends to a service area were created. Network locations have a monocentric configuration. Nevertheless, are points corresponding to the urgent care ser- secondary poles play an essential role at popu- vices and emergency facilities in the study area. lation and functional levels, resulting in pop- The defined parameters enabled creating acces- ulation dispersion. The city of Beja is the only sibility intervals (Isochrones) concerning a given major center (the only city with over 10,000 in- urgent care service or emergency means (NIME habitants). We have secondary centers, such as ambulances). Thus, the time required from the the cities of Moura and and the villages of emergency means to the user, and the user to the , Castro Verde, and urgent care services was counted. Subsequently, (Figure 1). accessibility was crossed with the sociodemo- graphic data of the geographic information refer- encing base of the National Institute of Statistics. Methods The mean density in each statistical subsection was calculated for all variables considered. Abso- The methodology underlying the calculation of lute numbers were not used to not overlap the accessibility results from applying the service population after cutting and intersecting statisti- area algorithm (network analyst), which allows cal subsections with accessibility polygons. calculating the range of a given location from a constraint factor32. The primary data structure for the calcula- Results and Discussion tion of accessibility is the road network. The fun- damental national network that may be observed Step 1 - Access to emergency services in Figure 1 includes three connections: A2/IP1 by own road mode (Valença–Castro Marim), which vertically cross- es the territory of Ferreira do Alentejo, Aljustrel, In the initial analysis, accessibility was calcu- Castro Verde, and Almodôvar; IP2 (Po lated, considering the three urgent care services. rtelo – Faro), also of a vertical profile; IP8 ( The minimum requirement for any inhabitant – Vila Verde do Ficalho) a horizontal connection to be 60 minutes at most from a BUS or a high- between Sines and Vila Verde de Ficalho. The er-level urgent care service was found to be ful- complementary national road network with IC filled. Approximately 38% of the population of 2488 Ferreira R et al. Ferreira

Figure 1. Baixo Alentejo Region – Location, Resident population by municipality and road network by category, 2018.

Source: Elaborated from INE, RGP data, 2011.

Baixo Alentejo access less than 10 minutes by car X-ray, a computed tomography scan (CT Scan), to one of the urgent care services, and no inhabi- or a magnetic resonance image (MRI), which tant needs more than 50 minutes to access one of enable the diagnosis of fractures, infections, and the services (Figure 2). pneumonia, among other common pathologies The methodology applied also enabled us to in acute episodes. draw some conclusions regarding the character- In an interview with the Director of the ur- istics of the population. Considering the analysis gent care service LHU of Baixo Alentejo, we con- by age structure, we find that the elderly popu- firmed that the basic urgent care service does not lation has a lower accessibility rate (Table 1). Si- have a CT Scan or MRI but only an X-ray. Al- multaneously, we identified that the population though the Castro Verde X-ray service is open 24 furthest from urgent care services was also the hours a day, the Moura X-ray service is only open least academically educated population. There between 8 am to 8 pm. Therefore, accessibility is was also a lower percentage of the employed significantly reduced at night because the service population and a higher percentage of the retired in Moura is not available. population. However, it should be noted that there are It is important to ascertain whether there differences in the services provided: the basic are complementary means of diagnosis such as urgent care service of Castro Verde and Moura 2489 Ciência & Saúde Coletiva, 26(Supl. 1):2483-2496, 2021

Alvito Cuba Moura Ferreira do Alentejo

Beja Serpa Aljustrel

Castro Verde

Ourique Mértola

Almodóvar Basic Urgency Care Service (Castro Verde) Basic Urgency Care Service (Moura) Medical-Surgical Urgency Care Service (Beja) Time distance ≤ 10 min. 11 - 20 min. 21 - 30 min. 31 - 40 min. ≥ 41 min.

0 10 20km

FigureFigure 2. 2. Accessibility Accessibility (time-distance) (time-distance) to urgency to urgency health healthcare services care services in Baixo inAlentejo, Baixo 2018.Alentejo, 2018 Source: Elaborated from INE, RGP data, 2011 Source: Elaborated from INE, RGP data, 2011.

Table 1. Accessibility (time-distance) of the resident ulation live less than 10 minutes away, and 61% population, by age group, to urgency health care of the population can reach the Medical-Surgical services in Baixo Alentejo, 2018. Urgent care Service (MSUS) by car in 30 minutes Accessibility or less. However, 2% of the population live 60 to Young Adult Elderly intervals 80 minutes away from the MSUS. population population population (time in (%) (%) (%) Greater geographical proximity to the Alente- minutes) jo was considered, namely Beja Hospital and Faro < 10 43 40 32 Hospital, when calculating the accessibility of an < 20 80 77 71 urgent care service of a higher level represented < 30 95 94 91 by the two multipurpose urgent care services. < 40 99 99 99 In this case, 10% of the population required 30 < 50 100 100 100 minutes or less to travel to one of these services. Source: Elaborated from data INE-RGP; DGS. In contrast, approximately 14% of the popula- tion take 60 minutes or more to access a MUS.

Step 2 - Accessibility of NIME’s medical respond to more straightforward emergencies, emergency facilities to the population while the Beja Medical-Surgical Urgent care Service (MSUS) is characterized by provid- Initially, the accessibility of the Emergency ing services of greater technical specificity. The Ambulance Service (NIME) network to the res- population living in Beja and the closest areas ident population was based on the assumption to that municipality benefit most from its loca- that all existing means can be activated, regard- tion. On the other hand, the population living in less of the specificity associated with each ambu- Barrancos and the southern area of Almodôvar, lance. In this context, the time-distance coverage Ourique, and Mértola have the lowest accessibil- is quite good since 85% of the population have ity rate to MSUS by car. Around 24% of the pop- an ambulance less than 10 minutes away, and 2490

Ferreira R et al. Ferreira 99% of the population 20 minutes or less. On the In situations that require more specialized other hand, and in the case of a more urgent sit- and urgent care, users are forwarded to high- uation requiring the activation of an Immediate er-level urgent care services and not to the near- Life Support Ambulance (LSA) or an Emergency est ones, where only 32% of the population can Medical and Resuscitation Vehicle (EMRS), the access the service in less than 20 minutes and 6% situation is similar to that calculated for acces- take over 1 hour by one of the 18 means. The cal- sibility to existing urgent care services, since the culations also enabled us to verify that the “corri- NIME means are located in the same units. dors” of greater accessibility are located between The streamlined situation (Figure 3), which the Hospital of Beja and the emergency means includes all emergency means and urgent care of the municipalities Ferreira do Alentejo, Alvito, services, suggests that approximately 31% of the Cuba, Vidigueira, Serpa, and Aljustrel. population can access the nearest urgent care ser- Finally, based on the two previous analyses, vice in less than 10 minutes and 24% require only we analyzed a third scenario, which involves us- 10 to 20 minutes. On the other hand, 20% of the ing NIME emergency means to access urgent care population takes more than 30 minutes to access services (Figure 4). the service. The elderly population is in the most On the other hand, the situation is even more disadvantageous situation as the highest propor- worrying if only Immediate Life Support Ambu- tion of these people lives within the farthest ac- lance (LSA) and Emergency medical and resusci- cessibility range. tation vehicle (EMRS) are considered: although

Alvito Cuba Vidigueira Moura Barrancos Ferreira do Alentejo

Beja Serpa Aljustrel Basic Urgency Care Service (Castro Verde) Basic Urgency Care Service (Moura) Medical-Surgical Urgency Castro Verde Care Service (Beja) EMC - Emergency Medical Mértola Centres Ourique RES - Reserv Centres LSA - Life Support Ambulance EMRS - Emergency medical Almodóvar and ressuscitation vehicle Time distance ≤ 10 min. 11 - 20 min. 21 - 30 min. 31 - 40 min. 41 - 50 min. 51 - 60 min. 61 - 80 min. ≥ 81 min.

0 10 20km

FigureFigure 3. 3. Accessibility Accessibility (time-distance) (time-distance) to urgent to urgent care service care serviceby NIME by emergency NIME emergency means, 2018. means, 2018 Source: Elaborated from data INE-RGP; DGS; NIME Source: Elaborated from data INE-RGP; DGS; NIME. 2491 Ciência & Saúde Coletiva, 26(Supl. 1):2483-2496, 2021

Beja Hospital EMC - Emergency Medical Centres RES - Reserv Centres LSA - Life Support Ambulance EMRS - Emergency medical and ressuscitation vehicle Time distance ≤ 10 min. 11 - 20 min. 21 - 30 min. 31 - 40 min. 41 - 50 min. 51 - 60 min. 61 - 80 min. ≥ 81 min.

0 10 20km

FigureFigure 4. 4 Accessibility. Accessibility (time-distance) (time-distance) to medical-surgical to medical-surgical urgent careurgent service care by service NIME byemergency NIME emergency means, 2018. means, 2018 Source: Elaborated from data INE-RGP; DGS; NIME. Source: Elaborated from data INE-RGP; DGS; NIME

21% of the population can access Medical-Sur- In Table 2, we can observe the six calculated gical Urgent care Service in less than 10 minutes, scenarios regarding the accessibility of the popu- around 70% of the population require more than lation to urgent care services using a NIME am- 30 minutes. Of these, 2% need more than 1 hour bulance. 30 minutes to reach an MSUS (Figure 5). The calculation showed the best results in- The last analysis assumes that the patient is cluded using all the means of pre-hospital emer- referred to a Multipurpose Urgent care Service gency in the study area (18 in total and at least (MUS), which corresponds to the emergency ser- one per municipality) to one of the three existing vices network’s most differentiated level. In this urgent care services (scenario 1). case, only 1% of the population was observed to In the cases requiring more differentiated live within 30 minutes of a BUS using one of the care, patients are not referred to a basic urgent 18 existing means of transport, and 47% took 60 care service but to medical-surgical urgent care minutes or more to reach that service (Figure 6). service or multipurpose urgent care service (sce- As mentioned above, the emergency means narios 5 and 6). In this situation, accessibility is may be activated by the European number by any most unfavorable and may require more signifi- citizen whenever their condition renders auton- cant effort on the urgency means in the patient’s omous travel by private car or public transport initial stabilization, namely heart attack, isch- unfeasible. emia, asthma attacks, childbirth, or accidents. 2492 Ferreira R et al. Ferreira

Alvito Cuba Vidigueira Moura Barrancos Ferreira do Alentejo

Beja Serpa Aljustrel

Beja Hospital Castro Verde LSA - Life Support Ambulance Ourique Mértola EMRS - Emergency medical and ressuscitation vehicle Time distance ≤ 10 min. Almodóvar 11 - 20 min. 21 - 30 min. 31 - 40 min. 41 - 50 min. 51 - 60 min. 61 - 80 min. ≥ 81 min.

0 10 20km

Figure 5. Accessibility (time-distance) to a medical-surgical urgent care service from a NIME Figure 5. Accessibility (time-distance) to a medical-surgical urgent care service from a NIME Immediate Life Immediate Life Support Ambulance (LSA) and Emergency Medical and Resuscitation Vehicle (EMRS),Support in AmbulanceBaixo Alentejo, (LSA) 2018. and Emergency Medical and Resuscitation Vehicle (EMRS), in Baixo Alentejo, 2018.

Source: Elaborated from data INE-RGP; DGS; NIME Source: Elaborated from data INE-RGP; DGS; NIME.

The lowest accessibility rate areas correspond For this case study, we observed that the to municipalities that are farthest from Mou- accessibility dimension is, in theory, ensured, ra-Beja-Castro Verde, such as Barrancos, the considering the minimum standards referred to southern border area, which includes the munic- throughout the legislation to provide services in ipalities of Serpa and Mértola. the urgent care and emergency services. Although many users travel to an urgent care service in their cars, an essential share of the regional popu- Conclusions lation with a high aging rate, low education level, and purchasing power below the national average The unequal distribution of health services be- does not have this privilege. This differentiated tween urban and rural areas has been highlighted pattern retreats age, socio-economic and territo- for most countries and cuts across health systems rial inequalities in access to health care. and countries in Europe. Frequently, local politi- In practical terms, we can conclude that, with cians and residents resist closing hospitals or pri- available equipment to provide the services, there mary care services in rural or remote areas. Nev- is not always real availability to access and use ertheless, besides the efficiency costs, we know them. For example, there was no X-ray service in that the quality of healthcare provision requires Moura basic urgent care service during the night a specific concentration of knowledge and expe- period. Thus, the pre-defined by law accessibil- rience, which is hard to guarantee in remote and ity is not guaranteed in 24 hours a day, and the sparsely populated areas. There is a public policy access in minimal time to emergency services is tendency of concentrating highly specialized ser- not assured. On the other hand, when placed as vices to combine efficiency and quality. However, extreme conditions of need for a medical emer- the concentration of services means lower acces- gency (LSA and EMRS) and support for high- sibility and lower access in low-density areas. er-level hospital urgency (Multipurpose Urgent 2493 Ciência & Saúde Coletiva, 26(Supl. 1):2483-2496, 2021

Alvito Cuba Vidigueira Moura Barrancos Ferreira do Alentejo

Beja Serpa Aljustrel EMC - Emergency Medical Centres RES - Reserv Centres Castro Verde LSA - Life Support Ambulance Mértola EMRS - Emergency medical and Ourique ressuscitation vehicle Time distance ≤ 30 min. 31 - 40 min. Almodóvar 41 - 50 min. 51 - 60 min. 61 - 80 min. 81 - 100 min. ≥ 101 min.

0 10 20km

Figure 6. Accessibility (time-distance) to a multipurpose urgent care service by a NIME emergency means, in Baixo Alentejo, 2018Figure 6. Accessibility (time-distance) to a multipurpose urgent care service by a NIME emergency means, in Source: ElaboratedBaixo from Alentejo, data INE-RGP; 2018. DGS; NIME

Source: Elaborated from data INE-RGP; DGS; NIME.

care Service-MUS), only 42% of the population particular, emergency and medical urgency in is attended within 60 minutes, while it takes up low-density territories. It does not mean that to 80 minutes to cover 70% of the population’s there should be an increase in hospitals in the demand in the region. Considering the full cov- region, but instead to ensure that the population erage of the region (100% of the resident popu- accesses the existing services quickly and effi- lation), the service could take until 130 minutes, ciently. We have three possibilities. which means more than 2 hours, to get support First of all, we can think of a reorganization in an urgent situation. of the service’s areas of influence. While the Por- On the other hand, it is troubling to see that tuguese health system is organized by regions, we older adults have the lowest accessibility rates, can suggest to generalize the possibility to refer and there are still a high number of residents users immediately to other hospitals or services with little or no education, especially in the more (from other regions) that can respond to the peripheral areas. This elderly population, for the emergency. This possibility means that screening reasons mentioned above, is in a more disadvan- is essential for referral cases, and time is not wast- tageous situation due to the lower capacity of ed traveling between health services that cannot these citizens for autonomous travel and conse- respond to a particular situation. The second quently their greater dependence on public trans- note relates to the need to better articulate the port, relatives, or emergency means. Inequalities emergency means and the various hospitals, and in access to “urgent” health care are reinforced, guarantee the availability of physical resources as this is also the population that resorts most to (such as means of diagnosis and therapy) and these services while also being further away from human resources (health professionals). This them. reinforcement may not represent replication of The work developed shows the need to re- means but strengthening communication devel- think the provision of health services and, in oped with e-health solutions. 2494 Ferreira R et al. Ferreira Table 2 . Emergency service network accessibility intervals from an emergency (2018). 1st scenario 2nd scenario 3rd scenario 4th scenario 5th scenario 6th scenario Consider the Consider the Consider the Consider the Consider the time- Consider the time- time-distance time-distance time-distance time-distance distance from one distance from LSA from one of the from LSA and from one of the from LSA and of the 18 existing and EMRS, NIME 18 existing NIME EMRS, NIME 18 existing NIME EMRS, NIME NIME ambulances ambulances, ambulances to ambulances, ambulances to a ambulances, to a to the nearest to the nearest Accessibility one of the three to one of the medical-surgical medical-surgical multipurpose multipurpose intervals urgent care three urgent urgent care urgent care urgent care service urgent care service services care services service in Beja service in Beja ∑ Resident ∑ Resident ∑ P Resident ∑ Resident ∑ Resident ∑ Resident population population population (2011) population population (2011) population (2011) (2011) (2011) (2011) Nº % Nº % Nº % Nº % Nº % Nº % < 10 39 687 31 39 748 31 26 857 21 26 913 21 0 0 0 0 < 20 69 853 55 48 280 38 41 099 32 30 276 24 0 0 0 0 < 30 101 164 80 67 036 53 63 544 50 38 562 30 1177 1 0 0 < 40 120 576 95 95 568 75 90 931 72 68 678 54 6554 5 0 0 < 50 124 148 98 112 827 89 105 574 83 88 255 70 16742 13 0 0 < 60 126 404 100 118 746 94 118 101 93 103 906 82 66928 53 53 481 42 < 70 126 560 100 124 174 98 124 915 99 114 923 91 88981 70 70 577 56 < 80 126 670 100 125 518 99 126 021 99 121 185 96 114 542 90 90 117 71 < 90 126 692 100 126 682 100 126 458 100 123 547 98 124 179 98 106 290 84 < 100 - - 126 692 100 126 571 100 124 642 98 126 183 100 119 018 94 < 110 - - - - 126 675 100 126 586 100 126 688 100 124 070 98 < 120 - - - - 126 692 100 126 686 100 126 692 100 125 518 99 < 130 ------126 692 100 - - 126 692 100 Source: Elaborated from data INE-RGP; DGS-Geosaúde; NIME.

Finally, in the case of municipalities whose Collaborations access times are more unfavorable, it is necessary to reinforce alternative means of an emergency, Work conception and design: R Ferreira, NM such as aerial means. Regardless of the proposed Costa, EM Costa. Theoretical framework: R Fer- solutions, it is worth emphasizing that the aging reira, and EM Costa. Selection of variables, col- target population with mobility difficulties and lecting data, selecting variables, and methodolog- lower-income prevalent in the Baixo Alentejo ical implementation: R Ferreira and NM Costa. territory is always an obstacle to emergency ser- Discussion of results: R Ferreira, NM, Costa, and vices. Thus, the need to reinforce prevention and EM Costa. Conclusions: R Ferreira, NM, Costa, primary health services is emphasized to reduce and EM Costa. the risk situations of populations. 2495 Ciência & Saúde Coletiva, 26(Supl. 1):2483-2496, 2021

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Article submitted 18/04/2020 Approved 11/08/2020 Final version submitted 13/08/2020

Chief editors: Maria Cecília de Souza Minayo, Romeu Go- mes, Antônio Augusto Moura da Silva

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