title: Equity aspects of the Primary Health Care Choice Reform in Sweden - a scoping review.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Department of Public Health Sciences, Equity and Health Policy Research Group, Karolinska Institutet, SE 171 77, Stockholm, Sweden. bo.burstrom@ki.se.
authors.forename: Bo
authors.initials: B
authors.lastname: Burström
authors.affiliation: Department of Public Health Sciences, Equity and Health Policy Research Group, Karolinska Institutet, SE 171 77, Stockholm, Sweden.|Department of Learning, Informatics, Management and Ethics, Health Outcomes and Economic Evaluation Research Group, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Kristina
authors.initials: K
authors.lastname: Burström
authors.affiliation: Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Gunnar
authors.initials: G
authors.lastname: Nilsson
authors.affiliation: Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Göran
authors.initials: G
authors.lastname: Tomson
authors.affiliation: Department of Public Health Sciences, Equity and Health Policy Research Group, Karolinska Institutet, SE 171 77, Stockholm, Sweden.|Department of Public Health and Society, Institute of Psychology, Health and Society University of Liverpool, Liverpool, UK.
authors.forename: Margaret
authors.initials: M
authors.lastname: Whitehead
authors.affiliation: Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Uppsala, Sweden.
authors.forename: Ulrika
authors.initials: U
authors.lastname: Winblad
mesh_terms: D002755:Choice Behavior; D018166:Health Care Reform; D000069576:Health Equity; D006296:Health Services; D006301:Health Services Needs and Demand; D006801:Humans; D009313:National Health Programs; D010342:Patient Acceptance of Health Care; D011320:Primary Health Care / Q000191:economics; D017149:Private Sector; D040841:Resource Allocation; D012923:Social Class; D012959:Socioeconomic Factors; D013548:Sweden
keywords: Equity; Health care need; Inequalities; Primary Health Care Choice Reform; Quality of care; Reimbursement system; Resource allocation