INEQUALITIES OF POPULATION ACCESIBILITY TO HEALTH CARE SERVICES IN THE BOTOSANI COUNTY (ROMANIA)

The population access to health care services is conditioned on the offer of medical services, which being unevenly distributed determines a limited access of the population, especially in rural areas. The inequalities in the distribution of health resources in Botosani County show a different accessibility levels to health services, depending on the living environment, but also on some financial, educational and social aspects. Using statistical data in the period 2000–2013 and spatial analysis, this paper focuses on the assessing and interpretation of the population accessibility indicators to health services in Botosani county – a small county located in the NE part of the Romania, and which is part of the poorest region of the Romanian country, in order to highlight the inequalities outlined in the county between the rural and urban areas. The inequalities of population accessibility to health care services are due to the lack of medical facilities, the poor quality of transport infrastructure and the lack of income.


INTRODUCTION
The accessibility to health care is a multidimensional concept and can be defined as theability of a population to achieve health care services. It varies across space because neither health professionals nor residents are uniformly distributed [Luo and Wang, 2003].
According to the European Observatory glossary produced on Health Systems and Policies, availability of health care is defined by the World Health Organisation (WHO) in 1998 as "measuring the proportion of the population with the access to medical services".
The optimum access to health care means a state of affairs characterized by the provision of care and timely intervention of medical staff or paramedical authorized in situations that require the presence of the provider of health services to the home or place in which the patient is.
The accessibility, after Penchansky and Thomas [1981] as cited in Black M. et al. [2005] and updated by Oliver and Mossialos [2004] as cited in Black M. et al. [2005], is measured by availability, acceptability and addressability (socio-economic, ethnic, age, sex, costs) and geographical or spatial and physical accessibility. The geographical accessibility measuring the level to which services are available and accessible to the population, being linked to the distribution of health care infrastructure in a specific region and the actual offer of the services and facilities [Final report..., 2008].
The geographical accessibility varies according to local conditions of transport, as local topography. Geographical accessibility is calculated as physical distance, in kilometers, between the residence and the nearest available medical service, but also to the nearest hospital or ambulance station. The calculation of these distances is done either in line, or in the existing line access routes (roads, highways, paths etc.) and is the time used to accede to a medical facility. There is no consensus on what constitutes "away" for a health care service, but usually it is considered that an optimal distance from a primary health care service should not be more than 5-7 km and a larger hospital 25-35 km [Jordan et al., 2004]. It is considered a great distance to a medical facility may adversely affect health status [Guagliardo, 2004, cited Black M. et al., 2000.
More important than the distances, is the travel time required to access health services, which describes the temporal accessibility. There are international standards for maximum travel time to health care: 30  Inequalities in spatial accessibility to health care are pronounced in many emergingcountries but also persist in developed countries where medically underserved areas are often encountered in rural areas [Joseph and Bantock, 1982, Fryer et al., 1999, Robst and Graham, 2004.
It considers that access to health is a precondition for active participation in society. At EU level there are two approaches to the development of universal access: tackling "needs and nothing more necessary" and addressing "equality" [ In the year 1974, Marck Lalonde emphasize that health can be influenced by four categories of factors including: economic development (50 %), genetic heritage, the lifestyle and the public health system, the main role in evaluating the quality of health returning to the quality of health services (15-20 %).
Because the Romanian health system is underfunded, as well as the health systems in Eastern European countries, the recent evaluations of the Romanian health system shows that it "has all the rankings red flashlight in European public health systems" [Deak, 2012].
In the last years the standard of living of the population has decreased continuously which is reflected in health care outcomes.
The inequalities in socio-economic development of the regions of Romania also influences health sector [Dragomiristeanu, 2010]. The limited state budget for health is responsible for the poor quality of health services system in Romania as a whole and the Botosani county. So that, a major concern of the Ministry of Health in Romania is to improve the access to health care services, especially for the rural population.
The differences between the richer regions and poorer, rural and urban, but also between people with high incomes compared to those with lower incomes are quite obvious for highlighting access to health services. [Gwatkin, 2001;Victoraetal, 2003]. Spatial accessibility to health service locations is usually measured through addressing the geographical barriers like travel distance or time [Cromley and McLafferty, 2012;Guagliardo, 2004].
Most existing measures of spatial accessibility are based on the potential interaction between health care providers (e.g., primary care physicians, cancer treatment centers,
A basic method is to measure average travel distance to nearest providers [Fryer Jret al., 1999;Goodman et al., 1992]. This method applies the straight line distance between the population point and the location of the health provider. However, travel routes are rarely straight lines in reality. It also cannot fully represent clusters of health providers in an urban setting and ignores the availability dimension of access. Last but not least, access to health care services is determined by the supply and demand, as this purely economic relationship functioning in health care systems.
The supply to health services characterized the access by: spatial distribution of these services; availability of staff working in these services; the quality of existing facilities; training of human resources; availability periods (program) and organizational services; type of transport, arrangements for physical access and the time required to travel. The demand affects access by individuals' attitude towards the disease, their knowledge of available services and the financial and cultural aspects of community members.
Moreover, access is also affected by timing and outcomes, and the receipt of good quality service when an individual needs it. Finally, equity in access needs to be considered for all groups in society who may differ in terms of need, socio-economic status, In this paper we analyze the geographical accessibility of population to health care services in Botosani county in terms of distance and time required for a patient to receive health care services and according to the distribution of health resources.
The highlighting of the inequalities in people's access to health services can be for the local authorities a starting point or a premise for development and modernization of transport network that would provide a easy access to health care facilities.

DATA AND METHODOLOGY
The methodology of research work includes two types of analysis: The accessibility's indicators to health care services were calculated based on distances and travel/driving times estimated using computer of Romania's road map available on Google in 2015, and they were verified on the field works with a personal car. The distances travel to the general practician offices were calculated from the house of patients to the general practician office, located usually in the center of the administrative unit. The distances of the travel to the nearest hospital were calculated like average distances from the center of the administrative units to the nearest hospital. But, it does not always express the real distance because the patients may find themselves closer to or further from health care provider or it is not always located just in the center of the commune. So, from this point of view the study has some gaps, for which we took into account the patients' average distance travel to an administrative unit.
In calculating the travel/driving times we taken into account the quality of the infrastructure of road and the weather conditions, that in winter increases the time necessary for a patient in order to access the health facilities. The winter meteorological conditions (blizzards, ice, fog) make that the roads become impassable and inaccessible for cars and means of public transport, making it impossible to move patients from rural areas to hospital, so that the travel time is doubles.
Also, often has been considered the available type of transport (car, means of transportation, or without transportation) and the average speed of transport in optimal weather or bad weather. The means of transport have a main role, because it facilitates the access to health care unit, for example a patient will get faster to general practician office if he uses a car than on foot. The unequal distribution of health resources and the poor quality of transport network in Botosani County (with only 56 % of the transport network in good condition) influence the population unequal access to health services.
In the last years the standard of living of the population has decreased continuously which is reflected in health care outcomes. A growing number of people have not opportunities to call the health services provided by private medical units and sometimes even to travel to the general practician offices if they are located at long distances. The public medical network shows large gaps, the main reason being the lack of funds and financial jams faced by most of hospitals.
To express synthetically the quality of healthcare infrastructure in Botosani we calculated the health care services index by standardizing and aggregating health services indicators presented in the methodology part.
In 2012, the health care services index has an average value of 0.138 at county level, slightly up compared to 2000 (0.081), but below the national average of this index (0.310).
In the representation of health care services we have established three classes of index values, so lead to the shaping of health care service areas.
From the mapping representation (Fig. 1), in the 35 administrative units the health services index is rather low (values under 0.100, marked on red in the map), which indicates the poor quality of health care services and highlights those administrative units that are poorly served by health services (the NV part of the Botosani County). The two maps show that the good covered area of health care services are the urban areas, and some communes (marked on green in the maps, where the health care index has values over 0.200). This outlines a pattern of distribution of health care resources that are better represented in urban areas (hotspots areas) and poorer in rural areas (shortage areas).
The downward trend of health care services index in some administrative units is the fact that the so-called reform process of the health services has not proven to be efficiently, leading to the cancellation of public hospitals, the occurrence of private specialized medical offices, where the population access to health services is limited by the reduced income and the decreasing of the medical staff.
GEOGRAPHY. ENVIRONMENT. SUSTAINABILITY. The low coverage with medical facilities in some areas of the county reflects on people's access to health care services, which is just prevented by the lack of medical facilities or that they are located far from the patient.

The accessibility factors of health care services
The access to the health services in Botosani county is influenced by several factors (Fig. 2): -physical-geographical factors: the relief, the weather conditions(forecasts); -socio-economic factors: the transport network (the quality of roads, type of transport), which means the time needed for traveling the distance to fulfill the request for medical services, or to use the services of an establishment providing health services, conditioned by the quality of transport network and the weather conditions, lack of financial resources.
-health factors: the health resources (number of medical units, number of beds, number of medical staff ).
In Botosani county, the analysis of physical-geographical factors is simple because the county's hilly relief is not a barrier to access the health facilities but the weather conditions may influence access to health services only in winter (snowstorm).
A limiting factor for access to health services in Botosani county is the quality of road network with only 56 % in good conditions (unpaved rural roads that become impracticable in winter) which determine higher times of transportation (travel time) for administrative units situated far away from urban centers providing health services (travel distance).

THE ANALYSIS OF SPATIAL ACCESSIBILITY
In appreciation of spatial accessibility to health services, a main role is held by transport infrastructure development. Most times, a long distance can be corrected or adjusted by the existence of a well-developed transport infrastructure (eg. paved road between the two points or proper development of a communication network that emergency services can reach the namely place).
Regarding the quality of roads one can say that in many administrative units of the Botosani county there are not paved road, and in a quarter of communes the distance from the nearest paved road is over 5 km. So, from the 650 km of county roads, only 56 % are in good condition.
The spatial accessibility of public health services was analyzed taking into account the average distance, that the patient has to cover up to the nearest medical unit (general practician office, hospital, permanent center, emergency unit).
In order to calculate the distances we considered the straight line distance between the nearest health care provider (which usually is located in the center of administrative units in the Botosani county) and the house of the patient who has health care needs.
Average distance from GP office is 4.8 km, which is above the average value recorded in Romania (4.2 km) 1 [Ciutan, 2008, p. 29].
These distances were calculated using road distance calculator available on Romania's road map (on the website: http://pe-harta.ro/ distante-rutiere.html) provided by Google in 2015.
From the map below (Fig. 3) we can see that 27 communes (32.6 % of total county population) are located at less than 4 km distance from a GP office, 28 communes (34.89 % of total county population) are located between 4-6 km from a GP office, 23 communes (32.5 % of total county population) are situated more than 6 km from a GP office (in some communes the access to health care services provided by GP offices is a longer distance of 7.8 km like in Santa Mare commune or 12 km like in Ripiceni).
Communes situated farther than the average value of 4.8 km from the GP office can be considered disadvantaged in terms of accessibility to primary health care.
The distance to the nearest hospital is an average of 21.9 km in Botosani county, which is close to the national average value calculated for this indicator in Romania (22 km) 2 [Ciutan, 2008, p. 30].
From the analysis of the map (Fig. 4) according to this indicator we can make the following remarks: 16  The patients from the 17 administrative units situated in the SE of the county (which represents 16.5 % of the county's population) travel a longer distance to the nearest hospital, outlined a disadvantaged area in the county.
The average distance traveled to the nearest ambulance station. In Botosani county there is only one ambulance station located in Botosani town, which is supplemented by an emergency unit. The distance to the nearest ambulance station has an average value of 39.5 km, well above the national average of 20 km, so that the optimal access to this health service can not be provided.
The spatial distribution of administrative units after this distance indicates: 14 administrative units travel less than 20 km to the nearest ambulance station (administrative units located near the Botosani city); 24 administrative units travel between 20-40 km to the nearest ambulance station; 29 administrative units travel between 40-60 km to the nearest ambulance station.

Fig. 3. Distribution of administrative units in Botosani county by average distance to GP office
The patients from11 administrative units (8.79 % of county's population) located in the N and SE part of the Botosani county travel a longer distance than 60 km to the nearest ambulance station).
The long distance to the nearest ambulance station means long travel time and some risk to the patients' health status.
In traveling these distances should be considered not only the necessary means of transport (car, minibus), but also the costs of transport which increase with the distance, and depending on the costs of fuels (gasoline, diesel).
It may be noted that the statistical indicators are almost identical to the average distances to the nearest hospital or to the nearest ambulance, explaining this by close historical relations between the location of ambulance stations and hospitals.
Due to the unequal distribution of health care resources and different distances traveled by patients to health care providers, a part of the population can not get access to health services, which can have consequences on population's health status by the occurrence of diseases or even deaths. The analysis of temporal accessibility The travel time, which depends on the type of transport that the patient has available, is more important to highlight the accessibility of health care.
The temporal accessibility was analyzed according to the time that the patients need in order to cover the distance to the nearest medical unit.   The long time access to health services is determined by the poor quality of county roads, 44 % of which are in mediocre condition and poor functionality.
The inequalities in travel time reflects on the population health outcomes, that may occur through worsening diseases if access to health services is not made in optimal time or badly, these may cause even deaths.

CONCLUSIONS
The analysis of available data shows that in rural areas, hospitals and ambulance stations are located at a distance over 30 km for the half of communes, so that it can not ensure better access of the population to hospital or emergency services. The time required for a patient to receive health services from hospital or ambulance station is also large enough for the rural population (over40 minutes).
The long distances to health care provider units and the long time needed to benefit on health care services determines the low accessibility to health care services in Botosani county which is caused by: -the poor quality of transport networks of Botosani county, which causes long travel time to healthcare providers (even longer in winter), -the poor quality and insufficient health care resources, which determines the long distance traveled by patients to the health care providers, -the adverse weather conditions in winter, which determine difficult county roads, thus increasing the time needed to travel to the nearest medical facility/hospital / ambulance station, -the insufficient financial and material resources, which is expressed by poverty and material deprivation, thus constituting a barrier to public access to health care.
The low accessibility of the population to health care services overlaps with urgent needs areas and high deprivation areas, which is reflecting on the population health outcomes.
There are strategies to improve the transport network in the Botosani county, but they should be correlate with the improvement of health infrastructure, so that these would reduce the inequalities in people's access to health services.