Jones MarciaHowever, the existence of low levels of utilization relative to need cannot be attributed to cost barriers alone, and it is clear that utilization patterns indicate a complex interplay of material, cultural, and geographic factors. This is clearly illustrated by a survey of eight health centers serving Māori and low-income New Zealanders, where GP utilization rates were significantly lower (37 to 74%) than the national average of 4.5 visits per capita in 1994/95. Given that the centers were established to improve access to Māori and low-income populations and have significantly reduced financial barriers compared to the average general practice, cost is clearly not a major factor in the observed very low utilization rates. In this case, cultural expectations of the benefits (or lack thereof) of the services provided were equally important.
This is underscored by a study by Crampton et al. of GP utilization rates in major “third sector” primary care organizations, all members of the Aotearoa Health Care network serving low-income populations with low or no co-payments. Like Malcolm, they found that overall GP utilization in per capita practices was low and much lower than in fee-for-service practices. However, in contrast to other studies, utilization rates for Māori were higher than for Pakeha for all age groups, reflecting the iwi base of multiple organizations and the importance of cultural and financial influences on utilization.
Geographic factors are also important for understanding levels of inequality in GP utilization. Given the strong correlations between distance and utilization patterns in both GPs and hospitals, it is not surprising that suboptimal utilization patterns are also locality-specific and result from the degree of “surplus” or “shortage” of GPs in a given area. This is clearly demonstrated by Malcolm, who showed that spending on poorer populations was 30% less than expected under the 1998 Health Care Financing Authority funding formula, compared to an undefined “affluent population”. population that was “overfunded” by 40%. Such patterns reflect the long-documented shortage of GPs in such areas and the impact of such barriers on limiting utilization. In contrast, demand driven by providers in wealthier regions with more physicians is potentially one reason why patients in such regions tend to receive more than their fair share of care, although there is still much debate about this issue.
