Decentralisation of services reduces geographical and social inequality in health
One of the aims of the upcoming health reform is to create a healthcare system that is closer to citizens and thereby address inequality in access to health services. Researchers have now examined whether the decentralisation of exercise-based cardiac rehabilitation can make a difference.
Exercise-based cardiac rehabilitation is a well-documented intervention that both reduces the risk of new cardiac events and improves quality of life. Nevertheless, many patients with heart disease drop out or choose not to participate at all. One of the most frequently cited reasons is distance: that rehabilitation services are located too far from where people live.
In a new scientific study, researchers from the Danish National Institute of Public Health have investigated whether the decentralisation of exercise-based cardiac rehabilitation—now part of municipal health services—has made a difference. And it has, explains senior researcher Kristine Bihrmann from the Danish National Institute of Public Health, one of the researchers behind the study:
“Geographical inequality has been significantly reduced. After rehabilitation services were moved from hospitals to municipalities, there are now more locations offering the service. This has led to an average reduction in travel distance of around 40 percent. It is particularly residents in rural areas and smaller towns who now have a much shorter distance than they did just a few years ago.”
Before the decentralisation, for example, some residents of Norddjurs Municipality had to travel more than 50 kilometres to reach the nearest service, while the municipal average was over 30 kilometres. Today, residents of Norddjurs Municipality have an average distance of less than 10 kilometres to the nearest service.
The study has just been published in the International Journal for Equity in Health. It is based on data from more than 2.4 million Danish addresses and nearly 3.7 million residents aged over 30. The researchers calculated travel distance from home to the nearest service in 2013 and 2023 and also analysed distances by, among other factors, level of education.
Moved closer to home
The study shows that before the decentralisation there was social inequality in access to the service, with certain vulnerable population groups having longer distances to rehabilitation.
“Older people, citizens with multiple chronic conditions, and those with lower levels of education have benefited the most from the decentralisation. The service has moved closer to their homes, and as a result social inequality in distance has been greatly reduced—if not eliminated,” says Kristine Bihrmann.
Among citizens whose highest completed education is primary school, the average travel distance was reduced from 15 to 8 kilometres after decentralisation. Citizens with a long higher education now have an average distance of 6 kilometres to exercise-based cardiac rehabilitation, compared with 9 kilometres previously.
The importance of ensuring quality
According to Kristine Bihrmann, the study illustrates what can be achieved when health services are brought closer to citizens.
“Our study shows that a local healthcare system reduces both geographical and social inequality in distance. It shortens travel distances especially for patients whom we know are less likely to participate in cardiac rehabilitation,” she says.
However, while the results indicate that shorter distances may make it easier for some patients to take part in cardiac rehabilitation, distance is not the only factor to consider when health services are decentralised.
“It is also important to ensure the quality of decentralised services. If staff see too few patients because the catchment area becomes too small, this can affect both routine and quality,” she says.
She stresses that this is a general observation. The cardiac rehabilitation services included in the study follow the recommendations of the Danish Health Authority and are continuously monitored through the Danish Cardiac Rehabilitation Database.
Kristine Bihrmann and her research colleagues will now investigate whether shorter distances are also reflected in increased participation in rehabilitation services—and thereby reduced inequality in health outcomes.
The study was funded by the Health Foundation (Helsefonden).
Facts: Exercise-based cardiac rehabilitation is offered to patients with heart disease and typically consists of a programme lasting several months. It includes, among other elements, physical training and support for lifestyle changes and disease management.
Average travel distance to exercise-based cardiac rehabilitation among citizens aged over 30 before and after decentralisation of services.
Contact: Senior researcher Kristine Bihrmann, Phone: +45 6550 7736, Email: akri@sdu.dk, Danish National Institute of Public Health, SDU