2.1 Principles of spatial organization and efficiency

This learning object considers the implications of different models of spatial organization for the efficiency of the health care system.

Delivery of health care presents a major societal cost, whether funded through general taxation, private insurance or out-of-pocket charges to patients. However funded, health care is not a ‘pure’ public good in the sense that it is impossible for it to be equally available to all members of the population: most health care services can only be provided at specific locations, ranging from the locations where a mobile clinic stops to the site of a major hospital. By contrast, demand for health care is essentially continuous over geographical space, at least in populated regions. The level of care which a society decides to spend on health care is a principal constraint on its organization. Viewed globally, the ratio of doctors to total population has been used as a basic indicator of the level of health care provision in different countries. This ratio critically sets the context for the spatial organization of care.

 
Medical specialties in which provision is sufficient to supply a service for populations of the order of a few thousands can realistically be organized as community-based services, while those provided once to hundreds of thousands or more will only be available in major urban centres of population. Increasingly specialised, technology-dependent medical care is most efficiently delivered from a few central locations which can benefit from many economies of scale. There is thus a tension between efficient and accessible service provision. An emphasis on preventive and primary care requires a large but not very specialised medical workforce, which may include village health workers, health visitors, nurses and general medical practitioners. Such a system depends for success on accessible local provision and is the foundation for many developing world health care systems. By contrast, a focus on a high-technology service will tend to lead to the clustering of care into major centres which minimize delivery costs but which present additional barriers to accessibility. The high costs of such care may not only be expressed in terms of geographical distance but in financial cost or waiting times. In market-oriented systems specialist treatment is only available to those with sufficient health insurance or who can afford to pay directly, while in state-funded systems care may be freely available but only at a level which requires extended waits for treatment.

High-level political decisions generally determine the amount of health care being supplied, through financial and regulatory controls. Even in contexts in which the health care system is strongly market-oriented, state provision usually provides some form of ‘safety net’ provision for those who are otherwise unable to access care. This type of provision is rarely the most efficient in financial terms. However, strongly market-oriented systems can be similarly financially inefficient because of the very high costs of administration and business functions which are not required in a centrally-funded health care system. There is thus frequently a tension between the spatial organization of health care for greatest accessibility and for service efficiency. Where different providers operate within the same national health care system, these may be operating to different objectives and their individual spatial organization strategies may differ widely.
 

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