Because of evidence of regional variation in health and healthcare use, this thesis used health equity and access to care theory to examine regional differences in access to primary care, using survey- as well as secondary data in four empirical studies. First, a systematic literature review was used to categorize forms and reasons for regional healthcare shortages and access barriers, with a particular focus on rural areas. After information extraction from the selected studies and a thematic content analysis, the forms and causes identified in the literature were grouped and discussed. Following the literature-based review of these thematic foundations, a study was then designed to evaluate patient-reported access to primary care in exemplary German regions and assess empirical differences in rural vs. urban populations. This allowed the importance to patients of different access dimensions to be evaluated. For a subgroup of study participants with multidisciplinary care needs, care coordination failures and the supportive role of the general practitioner as a primary point of access was investigated. Finally, regional factors that are associated with variations in need, health, and utilisation beyond individual health determinants were identified, and placed on different regional framework conditions. These health-related factors were summarised in a regional deprivation measure and small-scale regions in Germany were differentiated by their regional deprivation by the main dimensions (material, social, ecological). Finally, their association to regional health outcomes were cross-sectionally estimated. To reduce unwarranted access variation, while also taking the patient perspective (by region) into account, the thesis concludes with a chapter on implications. Here, concepts for regional and multidimensional access monitoring, as well as further regulatory measures in capacity and distribution planning of primary care, are discussed.:Content Tables ........................................................................................................................... V Figures ....................................................................................................................... VI Abbreviations ........................................................................................................... VII 1. Background and research objectives .................................................................. 9 1.1. Health equity and access to health care ........................................................ 10 1.2. Regional variation as a contradiction to the equity principle ....................... 16 1.3. Reducing unwarranted regional variation in health care .............................. 20 1.4. Research objectives and thesis structure ...................................................... 24 References ............................................................................................................... 28 Legal sources .......................................................................................................... 33 2. Rural health care shortages and access barriers ............................................. 34 3. Regional access and satisfaction with primary care........................................ 35 Appendix 3 .............................................................................................................. 36 4. Access to primary care and outpatient care coordination .............................. 48 4.1. Introduction .................................................................................................. 49 4.2. Background ................................................................................................... 51 4.2.1. The patient perspective of care coordination ......................................... 51 4.2.2. Coordinating mechanisms ..................................................................... 52 4.3. Methods ........................................................................................................ 55 4.3.1. Data collection and sample .................................................................... 55 4.3.2. Measures ................................................................................................ 55 4.3.3. Data analysis .......................................................................................... 58 4.4. Results .......................................................................................................... 59 4.5. Discussion and limitations ............................................................................ 62 4.6. Implications .................................................................................................. 65 References ............................................................................................................... 69 Appendix 4 .............................................................................................................. 73 5. Area deprivation and its impact on health ....................................................... 76 6. Summary of implications ................................................................................... 77 6.1. Establishing a framework to assess primary care access and performance .. 77 6.2. Strengthening patient involvement in health care structure planning .......... 81 6.3. Strengthening access to GPs as outpatient care coordinators ....................... 84 6.4. Including regional deprivation factors in health care structure planning ..... 86 References ............................................................................................................... 90

Bisher wurden die Einzugsgebiete der Gesundheitszentren mit den administrativen Grenzen des Sektors, in dem das Gesundheitszentrum liegt, gleichgesetzt. Das Hauptanliegen dieser Arbeit ist es, die tatsächlichen Einzugsgebiete zu erfassen und bisher verwendete methodische Ansätze auf ihre Eignung zu testen, Einzugsgebiete für Gesundheitszentren möglichst realistisch zu modellieren. Darüber hinaus sollen Gründe für räumliche Unterschiede in der Inanspruchnahme von Gesundheitszentren ermittelt werden. Fragenbögen, die mit Patienten in den Gesundheitszentren ausgefüllt wurden, sowie aus Registrierungsbüchern erfasste Daten geben Aufschluss über die räumlichen Unterschiede bei der Inanspruchnahme und dienen als Referenzdaten für die weiteren Analysen. Die Studie zeigt, dass keine der getesteten Methoden dazu geeignet ist, die Einzugsgebiete zufriedenstellend zu modellieren. Ein selbst entwickelter Ansatz, der verschiedene Methoden kombiniert, liefert bezüglich der Bevölkerung nur zweitbeste Ergebnisse nach Thiessen Polygonen, während für keine der Methoden die Grenzen mit den Grenzen übereinstimmen, die für die tatsächliche Nutzung ermittelt wurden. / Until now catchment areas of health centers are considered as the administrative boundaries of the sector where the health center is situated. The main objective of this study is to determine the actual catchment areas of health centers in Huye District (Southern Province, Rwanda) and to test approaches used in other studies in a geographical information system for an improved estimation of catchment areas. Furthermore reasons for disparities in health center utilization are to be revealed. Questionnaires filled with patients at health centers as well as data retrieved from registration books aim to give information about spatial disparities in health center utilization and serve as evaluation basis for further analysis. The study shows that none of the tested methods is able to predict catchment areas or the population to be served in a satisfying accuracy. An own approach that combines different methods gives only second best results after Thiessen polygons regarding the served population while for none of the methods the boundaries match well the catchment areas as they are defined by the data.