title: Accessibility to primary health care in Belgium: an evaluation of policies awarding financial assistance in shortage areas.
abstract: BACKGROUND
  In many countries, financial assistance is awarded to physicians who settle in an area that is designated as a shortage area to prevent unequal accessibility to primary health care. Today, however, policy makers use fairly simple methods to define health care accessibility, with physician-to-population ratios (PPRs) within predefined administrative boundaries being overwhelmingly favoured. Our purpose is to verify whether these simple methods are accurate enough for adequately designating medical shortage areas and explore how these perform relative to more advanced GIS-based methods.
  
  
  METHODS
  Using a geographical information system (GIS), we conduct a nation-wide study of accessibility to primary care physicians in Belgium using four different methods: PPR, distance to closest physician, cumulative opportunity, and floating catchment area (FCA) methods.
  
  
  RESULTS
  The official method used by policy makers in Belgium (calculating PPR per physician zone) offers only a crude representation of health care accessibility, especially because large contiguous areas (physician zones) are considered. We found substantial differences in the number and spatial distribution of medical shortage areas when applying different methods.
  
  
  CONCLUSIONS
  The assessment of spatial health care accessibility and concomitant policy initiatives are affected by and dependent on the methodology used. The major disadvantage of PPR methods is its aggregated approach, masking subtle local variations. Some simple GIS methods overcome this issue, but have limitations in terms of conceptualisation of physician interaction and distance decay. Conceptually, the enhanced 2-step floating catchment area (E2SFCA) method, an advanced FCA method, was found to be most appropriate for supporting areal health care policies, since this method is able to calculate accessibility at a small scale (e.g., census tracts), takes interaction between physicians into account, and considers distance decay. While at present in health care research methodological differences and modifiable areal unit problems have remained largely overlooked, this manuscript shows that these aspects have a significant influence on the insights obtained. Hence, it is important for policy makers to ascertain to what extent their policy evaluations hold under different scales of analysis and when different methods are used.
authors: Department of Geography, Ghent University, Krijgslaan 281, S8, B-9000 Ghent, Belgium. bartd.dewulf@ugent.be
authors: Bart
authors: B
authors: Dewulf
authors: Tijs
authors: T
authors: Neutens
authors: Yves
authors: Y
authors: De Weerdt
authors: Nico
authors: N
authors: Van de Weghe
mesh_terms: D001530:Belgium; D002391:Catchment Area, Health / Q000191:economics / Q000706:statistics & numerical data*; D005194:Family Practice / Q000191:economics / Q000706:statistics & numerical data*; D040362:Geographic Information Systems; D006291:Health Policy / Q000191:economics*; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand; D006302:Health Services Research; D006280:Health Workforce / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D008507:Medically Underserved Area; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors
references: Int J Health Geogr. 2004 Feb 26;3(1):3
references: 14987337
references: Health Serv Res. 1988 Dec;23(5):649-67
references: 3204015
references: Soc Sci Med. 2003 Jan;56(2):387-403
references: 12473323
references: J Rural Health. 1999 Winter;15(1):113-21
references: 10437338
references: Int J Health Geogr. 2012 Nov 16;11:50
references: 23153335
references: Int J Health Geogr. 2011 Jan 10;10:2
references: 21219597
references: Med Care. 1988 Jan;26(1):34-44
references: 3336244
references: Health Place. 2009 Sep;15(3):801-10
references: 19268622
references: Health Place. 2009 Dec;15(4):1100-7
references: 19576837
references: Int J Health Geogr. 2008 Feb 18;7:7
references: 18282284
references: Soc Sci Med. 2006 Mar;62(5):1291-303
references: 16129534
references: Acad Med. 1995 Jan;70(1 Suppl):S10-3
references: 7826450
references: Health Serv Res. 2003 Feb;38(1 Pt 1):287-309
references: 12650392
references: Socioecon Plann Sci. 1992 Oct;26(4):275-87
references: 10123094
references: Health Serv Res. 1974 Fall;9(3):208-20
references: 4436074
references: Environ Plann B Plann Des. 2003 Dec;30(6):865-884
references: 34188345
references: Aust N Z J Public Health. 2000 Oct;24(5):474-80
references: 11109683
references: Aust N Z J Public Health. 2009 Oct;33(5):418-23
references: 19811476
references: Med Care. 1983 May;21(5):543-57
references: 6843205
references: Ann Assoc Am Geogr. 2012;102(5):1104-1112
references: 23335813
references: Int J Health Geogr. 2012 Oct 10;11:43
references: 23046604
references: Soc Sci Med. 2009 Nov;69(9):1311-3
references: 19665828
references: J Med Syst. 2006 Feb;30(1):23-32
references: 16548411
references: J Health Soc Behav. 2005 Mar;46(1):15-31
references: 15869118
references: Health Policy. 2003 Aug;65(2):153-65
references: 12849914
references: BMC Health Serv Res. 2011 Jul 11;11:166
references: 21745402
references: Health Place. 2004 Mar;10(1):1-11
references: 14637284