En Suède, une réforme du système des soins de santé primaires récente donne au patient le droit de choisir son centre de soins et au fournisseur la liberté de choisir ses lieux d’implantations. La réforme prévoit une compensation financière destinée à favoriser le maintien ou l’installation de centres dans des territoires peu attractifs, comme les régions septentrionales faiblement peuplées. Malgré ce dispositif, de nombreux territoires ne parviennent pas à attirer de nouveaux centres. Cela explique, en partie, pourquoi d’autres stratégies se sont développées pour réduire les inégalités entre les territoires en termes d’accès aux soins. L’article interrogera les conséquences de la réforme sur l’accessibilité géographique aux soins, ainsi que les solutions à distance innovantes qui émergent de la recherche systématique de l’équité de l’accès aux soins de santé et de l’efficacité du système de soins, pour faire face aux tendances actuelles de vieillissement de la population et de stagnation des budgets.
In Sweden, since the 1990s, various reforms have sought to transfer hospital care to ambulatory care in primary care centers and to home care. In 2010, a reform of the primary health care system generalized the possibility for swedes to choose the primary care center where to be treated. The reform also gave caregivers in primary health the free choice of location of their establishments on the territory. Since this reform there is a competition between health care providers, as the payment received by the primary care centers depends on the number of patients and the on their profiles. Sweden has a low population density, especially in its northern part (less than two inhabitants per square kilometer in some territories) and the population is aging, even from a European perspective. In northern municipalities, between 25 and 30 per cent of the population is over 65 and in some municipalities more than 10 per cent of the population is 80 years old or more. One of the challenges of the Swedish health system is to maintain or even improve access to care in northern areas where needs are high, due to an elderly population prone to chronic diseases. In order to promote retention or installation of centers in low-density areas, which are not attractive to healthcare institutions despite significant care needs, a financial compensation system was implemented with the reform. The health policy is based on a payment by capitation, where the compensation varies according to the profiles and needs of the populations and the characteristics of the territories. Despite this arrangement, many territories fail to attract new centers, which partly explains why other strategies have been developed to reduce inequalities between territories in terms of access to care. These include a set of solutions that challenge the very definition of accessibility to care, disconnecting the place of care and caregiver, with the development of remote consultations and monitoring. The current paper examines the consequences of the primary health care reform and the development of e-health care on geographic accessibility to care. The systematic search for equity in access to health care and effectiveness of the health care system is clearly a response to current trends of population aging and stagnating budgets. A specific focus on the sparsely populated county of Västerbotten reveals a development strategy of innovative remote health care solutions. Since 2013, four consultation rooms have been equipped with videoconferencing equipment and measuring instruments and offers thus remote consultations and new virtual care centers are under implementation. The presence of virtual health care centers in the county of Västerbotten significantly reduces the distance between the inhabitants and the centers allowing access to a consultation with a specialist physician (figure 1). For example, without the existing and planned virtual centers, 10 per cent of the population is located more than 100 kilometers from a county hospital. The spatially regular distribution of the future virtual centers in the hinterland clearly improves the access to a specialist physician, since “only” 4.6 per cent would live more than 100 kilometers from one of the current or planned virtual health centers. The provision of remote care and on-site facilities for a virtual consultation with a medical specialist can replace a round trip to the regional hospital in Umeå. These centers therefore improve the situation in strict terms of accessibility to specialist and to primary care, when the virtual health room is spatially disconnected from a primary health center like the virtual health room in Slussfors (figure1). The aim of the development of remote monitoring, consultation and care centers is not to replace traditional care with the physical presence of a physician, but to supplement the service of traditional primary or specialist care units. There are, however understandable reservations about the extent to which particularly vulnerable and isolated populations who do not readily consult physicians for cultural, social or health-related reason might be disadvantaged by the development of remote health care.
