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Background: In June 2011 the Swedish government signed an agreement with The Swedish Association of Local Authorities and Regions (SALAR), for a three year project to develop and implement “Health care on equal terms.” The project, which involved seven Primary Health Care Units (PHCU) from five county councils in different parts in Sweden, was completed in early 2014. The aim of the project was to develop methods and activities that could promote more equal health care provision in socio-economically disadvantaged areas.

Aim: To assess and compare health care providers’ experiences of and perceptions about equitable health care at the beginning and end of the national project “Health care on equal terms”.

Methods: A web survey was sent to all staff at the seven participating Primary Health Care Units (PHCU) at the beginning (2012) and the end (2013) of the project. Data were analyzed with descriptive statistics and the open issues with content analysis.

Results: In 2013, the percentage of health care providers who reported thinking patients’ ethnicity had no or very little impact on access to care increased, but the proportion of those who reported that they had “no idea” that patients’ gender, age, mental health and physical functioning were significant for access to care was lower in 2013 than in 2012. The results from analysis of the open-ended questions did not show meaningful changes in the respondents’ perceptions of the issues addressed in 2012-2013, but the analysis contributes to a deeper explanation of the answers.

Conclusion: The main conclusion is that it was possible to implement changes aiming for more equitable care through projects with a focus on learning.

Background: This paper examines two state-led public–private demand-side financial support programs aiming to raise hospital delivery rates in two neighbouring Indian states—Gujarat and Madhya Pradesh. The national Janani Suraksha Yojana (JSY) was complemented with a public–private partnership program Janani Sahayogi Yojana (JSaY) in Madhya Pradesh in which private obstetricians were paid to deliver poor women. A higher amount was paid for caesarean sections (CS) than for vaginal deliveries (VD). In Gujarat state, the state program Chiranjeevi Yojana (CY) paid private obstetricians a fixed amount for a block 100 deliveries irrespective of delivery mode. The two systems thus offered an opportunity to observe the influence of supplier-induced demand (SID) from opposite incentives related to delivery mode. Methods: The data from the two programs was sourced from the Departments of Health and Family Welfare, Governments of Gujarat and Madhya Pradesh, India. Results: In JSaY program the CS rate increased from 26.6 % (2007–2008) to 40.7 % (2010–2011), against the background rate for CS in Madhya Pradesh, of only 4.9 % (2004–2006). Meanwhile in CY program in Gujarat, the CS rate decreased to 4.3 % (2010–2011) against a background CS rate of 8.1 % (2004–2006). Conclusions: The findings from India are unique in that they not only point to a significant impact from the introduction of the financial incentives but also how disincentives have an inverse impact on the choice of delivery method.

Introduction: The Swedish Health Care Law requires the health system to provide good care on equal terms to all. However, several reports from different governmental agencies have revealed that health care is uneven in quality, lacking in accessibility, and not offered on equal terms to all people. Recent public health reports show that inequalities in health in the population have increased. To provide health care on equal terms has become a challenge for health care.

In order to apply methods for developing practice and policy in promoting health and equity the Swedish Association of Local Authorities and Regions developed and implemented a national project entitled Care on Equal Terms. The project began in 2011 and was completed in 2014 at seven Primary Health Care Units (PHCUs) in five regions. The aim of this study was to evaluate the outcomes of this project.

Methods: Based on a program theoretical approach an evaluation design was developed which included process, results and economical evaluation. In the data collection and analysis mixed methods were applied.

Results: According to the process evaluation, seven different strategies were applied in the process to develop primary health care on equal terms. One of the key observations was that in order to achieve health on more equal terms, health care needs to be provided on unequal terms, i. e. more needs to be done to reach those who need more assistance to access health services. Health promotion was one of the applied strategies and it was the most common strategy at some of the health care centers with the aim of developing patients' knowledge, awareness and understanding about health, care and self-care. The results evaluation showed that the PHCUs staff identified structural and organizational factors in health care as important factors for developing health promotion and equity in access. The health economic evaluation showed that the costs for implementing the activities for an improved equity were limited. Yet the majority of the PHCUs thought that the detailed regulation of their financing and reporting requirements were a limitation in their work for improved equity. Four of five county councils have recently introduced a primary care provider payment system (ACG) which may not be supportive of efforts to improve equity in access.

Conclusions: It is possible to develop and maintain practices that can contribute to more equitable care and increase health care personnel’s awareness about practice and policy in promoting health and equity.

In 2002, the Chinese central government created a new rural cooperative medical system (NCMS), ensuring that both central and local governments partner with rural residents to reduce their copayments, thus making healthcare more affordable. Yet, significant gaps in health status and healthcare utilization persisted between urban and rural communities. Therefore, in 2009, healthcare reform was expanded, with (i) increased government financing and (ii) sharply reduced individual copayments for outpatient and inpatient care. Analyzing data from China's Ministry of Health, the Rural Cooperative Information Network, and Statistical Yearbooks, our findings suggest that healthcare reform has reached its preliminary objectives-government financing has grown significantly in most rural provinces, especially those in poorer western and central China, and copayments in most rural provinces have been reduced. Significant intraprovincial inequality of support remains. The central government contributes more money for poor provinces than for rich ones; however, NCMS schemes operate at the county level, which vary significantly in their level of economic development and per capital gross domestic products (GDP) within a province. Data reveal that the compensation ratios for both outpatient and inpatient care are not adjusted to compensate for a rural county's level of economic development or per capita GDP. Consequently, a greater financial burden for healthcare persists among persons in the poorest rural regions. A recommendation for next step in healthcare reform is to pool resources at prefectural/municipal level and also adjust central government contributions according to the GDP level at prefectural/municipal level.

Utvärderingen av SKL-projektet ’Vård på Lika Villkor’ visade att primärvårdensersättnings- och styrsystem genomgått stora förändringar under senare årmed olika utformning i landstingen. Primärvårdens ersättnings- och styrsystemi samtliga landsting i Sverige beskrivs och analyseras med särskild fokus påACG-systemet i en litteraturanalys med avseende på ACG-systemets effekterpå vårdens jämlikhet, innehåll kvalitet och effektivitet. Totalt har 51 relevantaartiklar analyserats. Slutsatsen är att studierna huvudsakligen avsett ACGsystemetsförmåga att predikera framtida vårdbehov, men att ingen av deanalyserade artiklarna har studerat effekter på vårdens jämlikhet, innehåll,kvalitet eller effektivitet. En brittisk studie visar dessutom att det finns en mycketenklare och mindre kostsam metod som dessutom predikerar vårdbehov bättreän ACG.

Sjukvården i Sverige är i dag inte jämlik, har brister i tillgänglighet och erbjuds inte på likvärdiga villkor trots Hälso- och sjukvårdslagens mål om en god hälsa och en vård på lika villkor för hela befolkningen.

För att bryta den pågående trenden och öka jämlikheten gjordes en överenskommelse mellan regeringen och SKL om lärandeprojektet Vård på lika villkor (under åren 2011–2014). Syftet med projektets har varit att inom socioekonomiskt resurssvaga bostadsområden öka jämlikheten i första linjens vård. Detta genom att testa, utveckla och identifiera effektiva arbetssätt och metoder vid sju primärvårdsverksamheter från fem landsting i Sverige.

Mälardalens högskola, Akademin för hälsa, vård och välfärd, fick av SKL i uppdrag att svara för forskarstöd och att genomföra en utvärdering av de metoder och arbetssätt som utvecklades och testades i lärandeprojektet.

Resultatet från den genomförda utvärderingen som belyser den genomförda processen, mål- och resultat samt hälsoekonomiska aspekter beskrivs närmare i denna rapport.

Introduction: Adherence to antiretroviral treatment (ART) is critical to maintaining health and good clinical outcomes in people living with HIV/AIDS. To address poor treatment adherence, low-cost interventions using mobile communication technology are being studied. While there are some studies that show an effect of mobile phone reminders on adherence to ART, none has reported on the costs of such reminders for national AIDS programmes. This paper aims to study the costs of mobile phone reminder strategies (mHealth interventions) to support adherence in the context of India's National AIDS Control Program (NACP). Methods: The study was undertaken at two tertiary level teaching hospitals that implement the NACP in Karnataka state, South India. Costs for a mobile phone reminder application to support adherence, implemented at these sites (i.e. weekly calls, messages or both) were studied. Costs were collected based on the concept of avoidable costs specific to the application. The costs that were assessed were one-time costs and recurrent costs that included fixed and variable costs. A sequential procedure for costing was used. Costs were calculated at national-programme level, individual ART-centre level and individual patient level from the NACP's perspective. The assessed costs were pooled to obtain an annual cost per patient. The type of application, number of ART centres and number of patients on ART were varied in a sensitivity analysis of costs. Results: The Indian NACP would incur a cost of between 79 and 110 INR (USD 1.27 - 1.77) per patient per year, based on the type of reminder, the number of patients on ART and the number of functioning ART centres. The total programme costs for a scaleup of the mHealth intervention to reach the one million patients expected to be on treatment by 2017 is estimated to be 0.36% of the total five-year national-programme budget. Conclusions: The cost of the mHealth intervention for ART-adherence support in the context of the Indian NACP is low and is facilitated by the low cost of mobile communication in the country. Extending the use of mobile communication applications beyond adherence support under the national programme could be done relatively inexpensively.

Lärandeprojektet Vård på lika villkor har varit en överenskommelse mellan staten och Sveriges Kommuner och Landsting som pågått mellan 2011 och 2014. Målet med projektet har varit att utveckla arbetssätt och metoder som kan främja en mer jämlik första linjens vård. Inom ramen för projektet har SKL uppdragit åt forskare vid Mälardalens högskola att göra områdesbeskrivningar för de sju medverkande vårdverksamheterna.

Syftet med områdesbeskrivningarna är försöka ge en jämförbar beskrivning av de medverkande sju verksamheterna i projektet. Beskrivningen är gjord utifrån relevant statistik och demografi ska data på patientnivå, samt utifrån organisatoriska förutsättningar och resurser. Förhoppningen är att dessa uppgifter kan ge ökad förståelse för vilka patienter som fi nns i området och fungera som ett stöd i arbetet för en mer jämlik vård.