Satisfaction with health systems in ten nations

Public satisfaction with health system after healthcare reform in China

BACKGROUND

The Chinese central government launched the third phase of health system reforms in 2009. After a decade since the initiation of the reform, the health system has witnessed noteworthy gains. However, there is no concurrent improvement in public satisfaction with the health system. This study analysed various factors that influence public satisfaction with the system and examined whether perceived quality of care affects public satisfaction.

METHODS

A longitudinal nationally representative survey was used for this study. We used five waves of China Family Panel Studies (CFPS) survey data. The final sample consisted of 145 843 observations. A two-way fixed-effects ordered logistic model was used for the analysis.

RESULTS

The results indicate that perceived good quality of care was positively associated with public satisfaction in health system regardless of rural-urban residence. Older adults and individuals with more than 3 years of college education were less likely to be satisfied with the system in rural areas. Personal income and the density of medical professionals in the geographic area tend to improve public satisfaction in rural areas. Having medical insurance coverage and fair or good self-rated health improved the probability of reporting public satisfaction in urban areas. Married people and individuals who lived in the West region were less likely to be satisfied with the health system in urban areas.

CONCLUSIONS

Knowledge and skills of healthcare providers or physical quality of facilities are not sufficient in improving public satisfaction in the health system. Policymakers need to identify options to influence the important factors that affect public perception of the system. This analysis identified several policy-amenable factors to improve public perception of the health system in rural and urban China.

Health system efficiency in OECD countries: dynamic network DEA approach

BACKGROUND

In recent years, measuring and evaluating the efficiency of health systems has been explored in the context of seeking resources to ensure the sustainability of 'countries' health and social systems and addressing various crises in the health sector. The study aims to quantify and compare the efficiency of OECD health systems in 2000, 2008, and 2016. The contribution to research in the field of efficiency in the healthcare system can be seen in the application of Dynamic Network Data Envelopment Analysis (DNDEA), which help us to analyse not only the overall efficiency of the healthcare system but analyse the overall efficiency as the result of the efficiencies of individual interconnected areas (public and medical care area). By applying the DNDEA model, we can realise the analysis not only within one year, but we can find out if the measures and improvements taken in the healthcare sector have a positive impact on its efficiency in a later period (eight-year interval).

METHODS

The analysis focuses on assessing the efficiency of the health systems of OECD countries over three periods: 2000, 2008, and 2016. Data for this study were derived from the existing OECD database, which provides aggregated data on OECD countries on a comparable basis. In this way, it was possible to compare different countries whose national health statistics may have their characteristics. The input-oriented Dynamic Network Data Envelopment Analysis model was used for data processing. The efficiency of OECD health systems has been analysed and evaluated comprehensively and also separately in two divisions: public health sub-division and medical care sub-division. The analysis combines the application of conventional and unconventional methods of measuring efficiency in the health sector.

RESULTS

The results for the public health sub-division, medical care sub-division and overall health system for OECD countries under the assumption of constant returns to scale indicate that the average overall efficiency was 0.8801 in 2000, 0.8807 in 2008 and 0.8472 in 2016. The results of the input-oriented model with the assumption of constant returns to scale point to the overall average efficiency of health systems at the level of 0.8693 during the period. According to the Malmquist Index results, the OECD countries improved the efficiency over the years, with performance improvements of 19% in the public health division and 8% in the medical care division.

CONCLUSIONS

The results of the study are beneficial for health policymakers to assess and compare health systems in countries and to develop strategic national and regional health plans. Similarly, the result will support the development of international benchmarks in this area. The issue of health efficiency is an intriguing one that could be usefully explored in further research. A greater focus on combining non-parametric and parametric models could produce interesting findings for further research. The consistency in the publication and updating of the data on health statistics would help us establish a greater degree of accuracy.

Is health politically irrelevant? Experimental evidence during a global pandemic

OBJECTIVE

To investigate how health issues affect voting behaviour by considering the COVID-19 pandemic, which offers a unique opportunity to examine this interplay.

DESIGN

We employ a survey experiment in which treatment groups are exposed to key facts about the pandemic, followed by questions intended to elicit attitudes toward the incumbent party and government responsibility for the pandemic.

SETTING

The survey was conducted amid the lockdown period of 15-26 April 2020 in three large democratic countries with the common governing language of English: India, the United Kingdom and the United States. Due to limitations on travel and recruitment, subjects were recruited through the M-Turk internet platform and the survey was administered entirely online. Respondents numbered 3648.

RESULTS

Our expectation was that respondents in the treatment groups would favour, or disfavour, the incumbent and assign blame to government for the pandemic compared with the control group. We observe no such results. Several reasons may be adduced for this null finding. One reason could be that public health is not viewed as a political issue. However, people do think health is an important policy area (>85% agree) and that government has some responsibility for health (>90% agree). Another reason could be that people view public health policies through partisan lenses, which means that health is largely endogenous, and yet we find little evidence of polarisation in our data. Alternatively, it could be that the global nature of the pandemic inoculated politicians from blame and yet a majority of people do think the government is to blame for the spread of the pandemic (~50% agree).

CONCLUSIONS

While we cannot precisely determine the mechanisms at work, the null findings contained in this study suggest that politicians are unlikely to be punished or rewarded for their failures or successes in managing COVID-19 in the next election.

TRIAL REGISTRATION

Initial research hypotheses centred on expected variation between two treatments, as set forth in a detailed pre-analysis plan, registered at E-Gap: http://egap.org/registration/6645. Finding no difference between the treatments, we decided to focus this paper on the treatment/control comparison. Importantly, results that follow the pre-analysis plan strictly are entirely consistent with results presented here: null findings obtained throughout.

Public satisfaction with health system coverage, empirical evidence from SHARE data

People's satisfaction with the health system, including the coverage provided, has been a concern for some years now but research into the main explanatory factors is in progress. This work focuses on European countries plus Israel, using the SHARE database to find what determines people's satisfaction with the basic coverage provided by the health system of each country. On top of the usual individual socioeconomic characteristics, other explanatory factors were also considered. These include, at individual level, trust in others, political positioning, and risk aversion; at country level, they include access to specialist care and the type of health system financing. Estimation of an ordered logistic model found that the main predictors for satisfaction with a health system's basic coverage include trust in others, unmet health needs, self-assessed health, free access to specialists, health system financed through social insurance, and out-of-pocket payments. These results provide the basis for possible policies designed to improve people's satisfaction.

Patient enablement after a consultation with a general practitioner-Explaining variation between countries, practices and patients

BACKGROUND

Patient enablement is a concept developed to measure quality in primary health care. The comparative analysis of patient enablement in an international context is lacking.

OBJECTIVE

To explain variation in patient enablement between patients, general practitioners (GPs) and countries. To find independent variables associated with enablement.

DESIGN

We constructed multi-level logistic regression models encompassing variables from patient, GP and country levels. The proportions of explained variances at each level and odds ratios for independent variables were calculated.

SETTING AND PARTICIPANTS

A total of 7210 GPs and 58 930 patients in 31 countries were recruited through the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. In addition, data from the Primary Health Care Activity Monitor for Europe (PHAMEU) study and Hofstede's national cultural dimensions were combined with QUALICOPC data.

RESULTS

In the final model, 50.6% of the country variance and 18.4% of the practice variance could be explained. Cultural dimensions explained a major part of the variation between countries. Several patient-level and only a few practice-level variables showed statistically significant associations with patient enablement. Structural elements of the relevant health-care system showed no associations. From the 20 study hypotheses, eight were supported and four were partly supported.

DISCUSSION AND CONCLUSIONS

There are large differences in patient enablement between GPs and countries. Patient characteristics and patients' perceptions of consultation seem to have the strongest associations with patient enablement. When comparing patient-reported measures as an indicator of health-care system performance, researchers should be aware of the influence of cultural elements.

Reaching minimal clinically important difference in adult spinal deformity surgery: a comparison of patients from North America and Japan

OBJECTIVE

The Scoliosis Research Society-22r questionnaire (SRS-22r) has been shown to be reliable, valid, and responsive to change in patients with adult spinal deformity (ASD) undergoing surgery. The minimal clinically important difference (MCID) is the smallest difference in a health-related quality of life score that is considered to be worthwhile or clinically important to the individual. The authors hypothesized that the proportion of patients with ASD achieving an MCID in the SRS-22r score would be different between two culturally different cohorts. The purpose of this study was to compare the proportion of patients with ASD achieving MCID for the SRS-22r domains in North American (NA) and Japanese cohorts.

METHODS

A total of 137 patients from North America (123 women, mean age 60.0 years) and 60 patients from Japan (56 women, mean age 65.5 years) with at least 2 years of follow-up after corrective spine surgery for ASD were included. Except for self-image, published Japanese MCID values of SRS-22r for ASD were higher (function = 0.90, pain = 0.85, self-image = 1.05, subtotal = 1.05) than the published NA MCID values (function = 0.60, pain = 0.40, self-image = 1.23, subtotal = 0.43).

RESULTS

There was a statistically significant improvement in all SRS-22r domain scores at 2 years compared to baseline in both cohorts. Except for mental health (NA = 0.32, Japanese = 0.72, p = 0.005), the mean improvement from baseline to 2 years was similar between the NA and Japanese cohorts. The proportion of patients achieving MCID was higher in North America for function (NA = 51%, Japanese = 30%, p = 0.006), pain (NA = 80%, Japanese = 47%, p < 0.001), and subtotal (NA = 72%, Japanese = 35%, p < 0.001), while there was no significant difference for self-image (NA = 53%, Japanese = 58%, p = 0.454).

CONCLUSIONS

Despite similar improvements in SRS-22r domain scores from baseline to 2 years postoperatively, the proportion of patients reaching SRS-22r MCID for function, pain, and subtotal after ASD surgery was higher in the NA cohort than in the Japanese cohort. This may imply that patients in North America and Japan may value observed changes in clinical status differently.

Protocol for a comparison study of 1-day versus 2-day prophylactic antibiotic administration in Holmium Laser enucleation of the prostate (HoLEP): a randomized controlled trial

Background: The best method of antimicrobial prophylaxis administration for surgical site infection (SSI) in transurethral holmium laser resection and enucleation of the prostate (HoLEP)/bipolar transurethral enucleation (TUEB) remains controversial. The purpose of this study is to compare one-day and two-day cefazolin in a randomized 2 nd-phase study to help establish a protocol with a 95% confidence interval (CI) for SSI prevention. Methods: Patients undergoing HoLEP/TUEB for benign prostate hyperplasia without preoperative pyuria will be enrolled and randomized to receive prophylactic antibiotic administration for HoLEP/TUEB in two groups, 1-day cefazolin and 2-day cefazolin. The primary endpoint is the occurrence rate of postoperative urinary tract infection or urogenital infection within 30 days after HoLEP/TUEB with a statistical 95% CI in comparison between those groups. Secondary outcomes include the kind of infectious disease and evidence of diagnosis, day of diagnosis of infectious disease, performance of urine or blood culture, detection of bacteria, treatments, duration of treatments, AEs other than surgical site infection, and drug-induced AEs. Discussion: The results of this study will provide evidence for defining the optimal duration of cefazolin prophylactic antibiotic administration for SSI. Trial registration: This study was registered in the University Hospital Medical Information Network-Clinical Trial Registry ( UMIN000027955) based on recommendations from the International Committee of Medical Journal Editors (ICMJE) on July 1 st 2017.

What Was Helpful Questionnaire (WHQ): Psychometric Properties of a Novel Tool Designed to Capture Parental Perceived Helpfulness of Interventions in Children Requiring Mental Health Inpatient Care

Background: Children in mental health inpatient care require multiple treatments. There is not a comprehensive instrument to assess perceived helpfulness of this combination of interventions. Aims: To develop and evaluate the psychometric properties of the What was Helpful Questionnaire (WHQ), a tool designed to capture parental perceived helpfulness of the multidimensional management approach used in inpatient children's units. Methods: A total of 73 inpatients and their families were included in this study. The WHQ consists of six items exploring the perceived helpfulness of different aspects of care. Demographic and clinical variables were collected on admission and discharge. An exploratory factor analysis using polychoric correlations was performed to assess the item structure of the scale and the Cronbach's alpha coefficient was used for internal reliability. Associations were assessed using regressions models. Results: WHQ is a unidimensional scale with an internal reliability of 0.77. No associations were identified between WHQ total score and age, gender, and Children's Global Assessment Scale scores change. A strong relationship between the WHQ total score and parental Acorn Satisfaction Questionnaire total score was found. Conclusions: Results add evidence for the validity and the reliability of the WHQ to measure parental perceived helpfulness of interventions offered in inpatient children's units.

The Canadian Plastic Surgery Workforce Analysis: Forecasting Future Need

BACKGROUND

Projecting the demand for plastic surgeons has become increasingly important in a climate of scarce public resource within a single payer health-care system. The goal of this study is to provide a comprehensive workforce update and describe the perceptions of the workforce among Canadian Plastic Surgery residents and surgeons.

METHODS

Two questionnaires were developed by a national task force under the Canadian Plastic Surgery Research Collaborative. The surveys were distributed to residents and practicing surgeons, respectively.

RESULTS

Two-hundred fifteen (49%) surgeons responded, with a mean age of 51.4 years (standard deviation [SD] = 11.5); 78% were male. Thirty-three percent had been in practice for 25 years or longer. More than half of respondents were practicing in a large urban center. Fifty-nine percent believed their group was going to hire in the next 2 to 3 years; however, only 36% believed their health authority/provincial government had the necessary resources. The mean desired age of retirement was 67 years (SD = 6.4). We predict the surgeons-to-population ratio to be 1.55:100 000 and the graduate-to-retiree ratio to be 2.16:1 within the next 5 to 10 years. Seventy-seven (49%) residents responded. Most were "very satisfied" with their training (61%) and operative experience (90%). Eighty-nine percent of respondents planned to pursue addqitional training after residency, with 70% stating that the current job market was contributing to their decision. Most residents responded that they were concerned with the current job market.

CONCLUSIONS

The results of this study predict an adequate number of plastic surgeons will be trained within the next 10 years to suit the population's requirements; however, there is concern that newly trained surgeons will not have access to the necessary resources to meet growing demands. Furthermore, there is an evident shortage of those practicing in rural areas. Many trainees worry about the availability of jobs, despite evidence of active recruitment. The workforce may benefit from structured career mentorship in residency and improved transparency in hiring practices, particularly to attract young surgeons to smaller communities. It may also benefit from a coordinated national approach to recruitment and succession planning.

Factors influencing patients' satisfaction at different levels of health facilities in Bangladesh: Results from patient exit interviews

There is a paucity in current literature about the level of patients’ satisfaction and factors influencing it in Bangladesh health system. We aimed to measure the level of patients’ satisfaction across different types and levels of healthcare facilities and to determine which factors influence this satisfaction level. A patient exit interview was carried out among 2207 patients attending selected health facilities in two administrative divisions of Bangladesh, namely Rajshahi and Sylhet. Information on healthcare experience and satisfaction with received care was collected through an electronic structured questionnaire. Information about ‘overall satisfaction with healthcare’ was collected on a 10-point scale and then dichotomized based on the median-split. Binomial logistic regressions, both simple and multivariable, were conducted to identify which factors contribute significantly to patients’ satisfaction. We found that 63.2% of the participants were satisfied with the healthcare service they received. Patients attending the private facilities had the highest level of satisfaction (i.e. 73%) and patients attending the primary care facilities had the lowest level of satisfaction (i.e. 52%). Factors like convenient opening hours, asking related questions to the providers, facility cleanliness and privacy settings were significantly associated with patients’ satisfaction. Being satisfied with facility cleanliness (multivariable OR 4.30; 95% CI: 3.29–5.62) and privacy settings (multivariable OR 1.68; 95% CI: 1.28–2.21) were the strongest predictors of patients’ satisfaction. In conclusion, a significant portion of the patients in Bangladesh are not satisfied with their received care. Patients’ satisfaction can be increased by focusing on improving facility cleanliness, privacy settings and providers’ interpersonal skills.

Cognitive determinants of healthcare evaluations - A comparison of Eastern and Western European countries

Knowing the public opinion of healthcare is essential when assessing healthcare system performance; but little research has focussed on the links between the public's general attitude to the healthcare system and its perceptions and expectations of specific healthcare-related aspects. Using data from the fourth round of the European Social Survey 2008/09, we explore the cognitive determinants of global evaluations of the healthcare system in 12 Eastern and 16 Western European countries. We find that healthcare evaluations follow a coherent cognitive reasoning. They are associated with (i) perceptions of the performance of healthcare systems (i.e. efficiency, equality of treatment, health outcomes), (ii) expectations of the government's role in providing healthcare, and (iii) reflections on demographic pressures (i.e. aging populations). Contrary to the general assumption that normative expectations are responsible for differences in healthcare evaluations between Eastern and Western Europe, our results suggest that regional differences are largely due to a more negative perception of the performance of healthcare systems within Eastern Europe. To enhance the public opinion of healthcare, policy makers should improve the efficiency of healthcare systems and take measures to assure equality in health treatment.

Satisfaction of breast cancer patients regarding surgery and radiation therapy: A survey in Japan

Purpose

To evaluate patient satisfaction in Japan and factors, including timing factors, cost, and specific medical practices derived from Western influence (shared decision-making and second opinion), which might affect satisfaction.

Methods and materials

All patients who presented to 1 large Japanese department of radiation oncology for postoperative radiation therapy for breast cancer from September 2010 to November 2013 were included in this study. The questionnaire was distributed to patients after the radiation oncologist consultation, and patients were asked to complete it anonymously by the end of treatment. We measured patient satisfaction with overall treatment and for each treatment separately (surgery, radiation oncology). We further inquired regarding facts that could affect satisfaction, including time from diagnosis to treatment start, waiting time in waiting room for consultation, average length of consultations, out-of-pocket cost for breast cancer treatment, patients' opinion of the cost, level of inclusion of the patient in decision-making, level of the patient sharing her feelings with her physician, and whether the patients had asked for second opinion.

Results

Of 364 patients surveyed, 214 (58.5%) responded. Overall satisfaction and satisfaction with surgeon and with radiation oncologist were 95.7%, 98.5%, and 98.2%, respectively. Factors correlated with satisfaction were waiting time for the consult in the waiting room, treatment cost, and perceived degree of sharing feelings with physicians. Overall, 27 patients (12.6%) reported having asked for second opinions. Of those who did not seek a second opinion, most (173) indicated that they did not think it was necessary.

Conclusions

In a large, typical Japanese radiation oncology practice, breast cancer patients' satisfaction correlated with waiting time, cost, and the rate with which the patient shared her feelings with her physician. This illuminates targets for quality improvement within the Japanese system and provides interesting cross-cultural comparative data for other countries in which the context of care may differ.

Racial Differences in Satisfaction with Physicians

This analysis examines the association between race and satisfaction with physicians among a sample of community-dwelling older adults. It is hypothesized that minority elderly will hold more negative attitudes toward physicians than will their White peers due to the difficulty in establishing rapport in the physician-patient relationship. Using data from the Established Populations for Epidemiologic Studies of the Elderly (Duke), we find that African Americans believe that physicians do not display much compassion for, and respect toward, the elderly. However, African Americans report more positive attitudes about the prudence of physicians. These findings are discussed in the context of improving the physician-patient relationship.

Public satisfaction with the healthcare system performance in South Korea: Universal healthcare system

BACKGROUND

An awareness of the public's level of satisfaction with health professionals is becoming more important as steps are being taken to improve quality, reduce costs, and implement reform. The purpose of this study is to assess public satisfaction with the healthcare system and to examine the relationship between satisfaction and socio-demographic factors in the context of the health care environment in the Republic of Korea.

METHODS

The data were obtained from 1573 adults aged 20-69 in three major areas - Seoul, Gyeonggi, and Busan - by the Ministry of Health and Welfare during June and July 2011 in South Korea. Satisfaction with the healthcare system was evaluated by using 13 items in three sections: access to care, cost of care, and quality of care. A confirmatory factor analysis (CFA) was conducted to examine the validity of satisfaction with a healthcare system performance questionnaire. A structural equation model (SEM) was estimated to assess the relative impact of demographic and socio-economic variables on satisfaction.

RESULTS

The study proposed a comprehensive three-factor model of healthcare system performance satisfaction. Among the three factors, the quality of care had the largest impact on satisfaction with the healthcare system, suggesting that is the most important determinant of consumers' satisfaction with their healthcare system. Regarding the relationships between public satisfaction and demographic and socio-economic variables, residence and marital status were significant predictors of the satisfaction level.

CONCLUSIONS

It is important to be aware of the potential significance of background variables in determining satisfaction with the healthcare system. An understanding of the characteristics of the sample enables healthcare managers and/or policymakers to inform targeted follow-up actions.

Factors influencing consumer satisfaction with health care

The purpose of this study was to examine factors that impact consumer satisfaction with health care. This is a secondary analysis of the Center for Studying Health System Change's 2010 Health Tracking Household Survey. Regression analysis was used to examine the impact of treatment issues, financial issues, family-related issues, sources of health care information, location, and demographics-related factors on satisfaction with health care. The study involved 12280 subjects, 56% of whom were very satisfied with their health care, whereas 66% were very satisfied with their primary care physician. Fourteen percent of the subjects had no health insurance; 34% of the subjects got their health care information from the Web. Satisfaction with primary care physician, general health status, promptness of visit to doctor, insurance type, medical cost per family, annual income, persons in family, health care information from friends, and age significantly impacted satisfaction with health care. The regression models accounted for 23% of the variance in health care satisfaction. Satisfaction with primary care physicians, health insurance, and general health status are the 3 most significant indicators of an individual's satisfaction with health care.

Comparisons of health care systems in the United States, Germany and Canada

The purpose of this research paper is to compare health care systems in three highly advanced industrialized countries: The United States of America, Canada and Germany. The first part of the research paper will focus on the description of health care systems in the above-mentioned countries while the second part will analyze, evaluate and compare the three systems regarding equity and efficiency. Finally, an overview of recent changes and proposed future reforms in these countries will be provided as well. We start by providing a general description and comparison of the structure of health care systems in Canada, Germany and the United States.

Satisfaction with healthcare services among Spanish people with disabilities

BACKGROUND

Several studies show the relationship between patient satisfaction and quality of health services and also between disabling conditions and healthcare access, but none sufficiently analyze the factors that contribute to satisfaction among patients with disabilities.

OBJECTIVE/HYPOTHESES

The primary aim of this paper is to quantify the impact of social factors, perceived health status and access on satisfaction with healthcare services among Spanish people with disabilities.

METHODS

This paper uses data from the European Health Survey 2009 to construct latent variables related to satisfaction, use and health status among Spanish patients with disabilities. Next, partial least squares path modeling is used for quantifying the effects of certain social factors, service use, and health status on patient satisfaction with received healthcare services.

RESULTS

Satisfaction with healthcare services among people with disabilities is correlated (Nagelkerke R(2) of 0.175) with certain demographic factors (age, gender and town size), assistance support and patient use of these services. Education level and income were not found to have significant effects.

CONCLUSIONS

People with disabilities generally show a high level of satisfaction with healthcare services, influenced by a positive valuation of the differentiated use given their specific care needs. Subjective aspects of care have a notable influence, linked with the perception of the person's own state of health and emotional status, on these positive valuations; patients' individual perceptions can reduce care needs and the use patients make of healthcare services and tend to increase their level of satisfaction with these services when they do seek them.

The gap between physicians and the public in satisfaction with the National Health Insurance system in Korea

The Korean National Health Insurance (NHI) system was an unprecedented accomplishment that was achieved in a short period of time. In this study, we sought to identify gaps between physicians and the public with respect to attitudes toward the NHI system in Korea. The study population was derived from the 2008 Korean Medical Association Survey, which was conducted to investigate satisfaction with and perceptions of the NHI system among physicians (n = 961) and the public (n = 935). Only 6.5% of the physicians were satisfied with NHI system, and 71.5% were dissatisfied with it. In contrast, 28.3% of the public were satisfied with the NHI system, and 21.4% were dissatisfied. The level of dissatisfaction expressed by physicians (2.03 ± 0.91 on a five-point scale) was also higher than that expressed by the public (3.06 ± 0.84). Despite rapid growth of NHI system, a large gap in satisfaction exists between physicians and the public.

Survey in sub-Saharan Africa shows substantial support for government efforts to improve health services

Public opinion can play an important role in shaping health policy alternatives and outcomes. However, little is known about how citizens in developing countries evaluate government performance in the health sector. Through a survey conducted in 2008 in twenty sub-Saharan African countries, we examined public priorities and perceptions of government efforts to improve health services. In sixteen of these countries, health was one of the top five priorities the public thought the government should address. A staggering proportion of citizens in most of the sampled countries reported having gone without medicines or medical treatment in the previous year, and going without health care was most strongly correlated with views on health services. By contrast, greater access to health care was associated with more positive impressions of government efforts to improve health services. Population health indicators, such as life expectancy and childhood mortality, were not correlated with citizens' evaluation of government efforts. Results suggest that improving access to health care will be a key factor in improving perceptions of government performance.

Public views of health system issues in four Asian countries

To elicit the public's views on health system issues, we conducted an opinion poll survey in Bangladesh, Mongolia, Nepal, and Sri Lanka. We focused on health inequalities. The results show high levels of dissatisfaction with government health services in all four of the countries. Access to government health services was an important concern. A sizable number of respondents reported that their governments did not consider their views at all in shaping health care services. The policy implications of the study findings are discussed.

Policy, Payment, and Participation: Long-Term Care Reform in Ontario

Although Canadian Medicare gives the population “reasonable” access” to all “medically necessary” physician and hospital services, long-term care is not formally subject to those conditions. In Ontario, long-term care involves a “patchwork quilt” of government, charitable, for-profit, and personally-provided services; an ongoing consultation has been under way in an attempt to rationalize service financing and provision. This paper reviews the series of policy proposals and the accompanying public consultation processes. It concludes that the emphasis on “community involvement” without a clear definition of “community” or the goals of participation has paradoxically increased the “scope of conflict,” increased frustration among stakeholders, and made policy action more difficult.

Espiritualidade na educação popular em saúde

A dimensão espiritual sempre esteve presente em grande parte das práticas de educação popular, mas de forma não claramente reconhecida nas análises teóricas. O instrumental teórico dos estudos sobre espiritualidade permite entender muitas dimensões emocionadas e simbólicas que são marcas centrais da dinâmica educativa destas práticas. Este trabalho procura refletir o significado da espiritualidade como instrumento e espaço de relação educativa entre profissionais e usuários dos serviços de saúde, na luta pela saúde, foco usualmente não discutido nos estudos teóricos predominantes sobre o tema.

How does satisfaction with the health-care system relate to patient experience?

OBJECTIVE

To explore what determines people's satisfaction with the health-care system above and beyond their experience as patients.

METHODS

Data on health system responsiveness, which refers to the manner and environment in which people are treated when they seek health care, provides a unique opportunity to better understand the determinants of people's satisfaction with the health-care system and how strongly this is influenced by an individual's experience as a patient. The data were obtained from 21 European Union countries in the World Health Survey for 2003. Additive ordinary least-squares regression models were used to assess the extent to which variables commonly associated with satisfaction with the health-care system, as recorded in the literature, explain the variation around the concept of satisfaction. A residual analysis was used to identify other predictors of satisfaction with the health-care system.

FINDINGS

Patient experience was significantly associated with satisfaction with the health-care system and explained 10.4% of the variation around the concept of satisfaction. Other factors such as patient expectations, health status, type of care, and immunization coverage were also significant predictors of health system satisfaction; although together they explained only 17.5% of the observed variation, while broader societal factors may largely account for the unexplained portion of satisfaction with the health-care system.

CONCLUSION

Contrary to published reports, people's satisfaction with the health-care system depends more on factors external to the health system than on the experience of care as a patient. Thus, measuring the latter may be of limited use as a basis for quality improvement and health system reform.

Medication use and patient satisfaction: a population-based survey

BACKGROUND

In recent years, there is a growing interest to assess patients' satisfaction which further triggers the existing debate on the severe methodological issues regarding the interpretation of comparative surveys results.

OBJECTIVE

This cross-sectional national survey aimed to examine satisfaction of Greek households with specific aspects of medication use and their correlates.

METHODS

Between November 2004 and February 2005, telephone interviews were used for collecting information about socio-demographic and health-related characteristics in a systematic sample of 1000 Greek households. Respondents were classified into three categories: chronic or short-term prescribed medication use, occasional medication use and no medication use during the 3 months preceding the survey. Satisfaction was assessed through various aspects of medication use like physician's consultation, physician's response to adverse events, consultation and advice by pharmacists, symptoms' resolution, route of drug administration, drug tolerability and drug cost.

RESULTS

The prescribed drugs' use in the 3 months preceding the survey interview was 36.9%; 28.6% for subjects under chronic treatment and 8.3% under short-term treatment. During the same time period, 52.8% of the respondents reported the occasional self-use of over the counter drugs for minor symptoms. A high prevalence of hypertension, cardiovascular, musculoskeletal and endocrine disorders has been observed. In general, respondents expressed a high degree of satisfaction with all aspects of medication use examined, the only exception being costs. Age, area of residence, social insurance scheme and self-reported health status were associated with specific aspects of patient satisfaction.

CONCLUSIONS

Patient satisfaction with the aspects of medication use examined seems to be influenced by demographic and social factors; this points out to the necessity of taking into account socio-cultural variations and the structure of the health-care system in policymaking.

Fact and fiction: debunking myths in the US healthcare system

The United States has the most expensive and complex healthcare system in the world. Despite the magnitude of funds spent on the system, Americans do not achieve the high standards of health seen in other developed countries. The current model of health insurance has failed to deliver efficient and effective healthcare. The administrative costs and lack of buying power that arise out of the existing multipayer system are at the root of the problem. The current system also directly contributes to the rising number of uninsured and underinsured Americans. This lack of insurance leads to poorer health outcomes, and a significant amount of money is lost into the system by paying for these complications. Experience from other countries suggests that tangible improvements can occur with conversion to a single-payer system. However, previous efforts at reform have stalled. There are many myths commonly held true by both patients and physicians. This inscrutability of the US healthcare system may be the major deterrent to its improvement. A discussion of these myths can lead to increased awareness of the inequality of our healthcare system and the possibilities for improvement.

Is there an association between economic performance and public satisfaction in health care?

Earlier studies on the association between health systems' economic performance and public satisfaction were based on between-countries comparisons. This approach can be challenged as it ignores the fact that subjective measures like 'satisfaction' might be relative. Cohort analysis is a way of dealing with this issue as it focuses on within-countries comparisons. The association between change in satisfaction with health care systems and change in economic performance, determined by an output-orientated constant returns to scale DEA Malmquist model over the period 1995 to 2000/2002 using OECD data, is explored. The results show that a health care systems' economic performance is not associated with public satisfaction.

Public trust in health care: a comparison of Germany, The Netherlands, and England and Wales

This article describes public trust in health care in three European countries. Public trust is a generalised attitude, influenced by people's experiences in contacts with representatives of institutions, in its turn influencing how people enter these contacts. In general, people in Germany have less trust in health care, while people in England and Wales have the highest trust levels. Cultural differences between the three countries could be an important source of differences. That makes public trust a less straightforward candidate for use as indicator of the future oriented dimension of user views in an international, comparative performance framework.

The politics of public health policy

Politics, for better or worse, plays a critical role in health affairs. The purpose of this article is to articulate a role for political analysis of public health issues, ranging from injury and disease prevention to health care reform. It begins by examining how health problems make it onto the policy agenda. Perceptions regarding the severity of the problem, responsibility for the problem, and affected populations all influence governmental responses. Next, it considers how bounded rationality, fragmented political institutions, resistance from concentrated interests, and fiscal constraints usually lead political leaders to adopt incremental policy changes rather than comprehensive reforms even when faced with serious public health problems. It then identifies conditions under which larger-scale transformation of health policy can occur, focusing on critical junctures in policy development and the role of policy entrepreneurs in seizing opportunities for innovation. Finally, it reviews the challenges confronting officials and agencies who are responsible for implementing and administering health policies. Public health professionals who understand the political dimensions of health policy can conduct more realistic research and evaluation, better anticipate opportunities as well as constraints on governmental action, and design more effective policies and programs.

Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey

OBJECTIVES

We compared health status, access to care, and utilization of medical services in the United States and Canada and compared disparities according to race, income, and immigrant status.

METHODS

We analyzed population-based data on 3505 Canadian and 5183 US adults from the Joint Canada/US Survey of Health. Controlling for gender, age, income, race, and immigrant status, we used logistic regression to analyze country as a predictor of access to care, quality of care, and satisfaction with care and as a predictor of disparities in these measures.

RESULTS

In multivariate analyses, US respondents (compared with Canadians) were less likely to have a regular doctor, more likely to have unmet health needs, and more likely to forgo needed medicines. Disparities on the basis of race, income, and immigrant status were present in both countries but were more extreme in the United States.

CONCLUSIONS

United States residents are less able to access care than are Canadians. Universal coverage appears to reduce most disparities in access to care.

What is important in evaluating health care quality? An international comparison of user views

BACKGROUND

Quality of care from the perspective of users is increasingly used in evaluating health care performance. Going beyond satisfaction studies, quality of care from the users' perspective is conceptualised in two dimensions: the importance users attach to aspects of care and their actual experience with these aspects. It is well established that health care systems differ in performance. The question in this article is whether there are also differences in what people in different health care systems view as important aspects of health care quality. The aim is to describe and explain international differences in the importance that health care users attach to different aspects of health care.

METHODS

Data were used from different studies that all used a version of the QUOTE-questionnaire that measures user views of health care quality in two dimensions: the importance that users attach to aspects of care and their actual experience. Data from 12 European countries and 5133 individuals were used. They were analysed using multi-level analysis.

RESULTS

Although most of the variations in importance people attach to aspects of health care is located at the individual level, there are also differences between countries. The ranking of aspects shows similarities. 'My GP should always take me seriously' was in nearly all countries ranked first, while an item about waiting time in the GP's office was always ranked lowest.

CONCLUSION

Differences between countries in how health care users value different aspects of care are difficult to explain. Further theorising should take into account that importance and performance ratings are positively related, that people compare their experiences with those of others, and that general and instrumental values might be related through the institutions of the health care system.

Taking The Pulse Of Health Care Systems: Experiences Of Patients With Health Problems In Six Countries

This paper reports on a 2005 survey of sicker adults in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. Sizable shares of patients in all six countries report safety risks, poor care coordination, and deficiencies in care for chronic conditions. Majorities in all countries report that mistakes occurred outside the hospital. The United States often stands out for inefficient care and errors and is an outlier on access/cost barriers. Yet no country consistently leads or lags across survey domains. Deficiencies in transition care during hospital discharge and coordination failures among patients seeing multiple physicians underscore shared challenges of improving performance across sites of care.

Impact of national health care systems on patient evaluations of general practice in Europe

OBJECTIVE

To examine associations between patient evaluations of general practice and characteristics of national health care systems.

METHODS

International comparative study in 17 countries, using international patient survey data (n= 25052) and data-bases for health care system characteristics. Dependent variable was patients' evaluation of general practice care. Five independent factors were examined: GP density, physician density, fee for service reimbursement, gatekeeper role, and first-contact role.

RESULTS

None of the associations were statistically significant.

CONCLUSIONS

Patients were highly satisfied with general practice in different national health care systems. Descriptive tables on international variations may lead to misleading conclusions.

The "managed care" idea: implications for health service systems in Australia

The growth of corporatism in health-care in the US, and the consequences arising from US models of health-care delivery systems provide an enormously valuable point of comparison with health systems of other developed economies, such as Australia. If lessons are to be learnt from the US, then an analysis of the structure and performance of the US health-care system provides important background for understanding and assessing contemporary policy changes to administrative and organizational designs and techniques for patient care in Australia.

Israelis evaluate their health care system before and after the introduction of the national health insurance law

This article reports on the evaluation of the Israeli health care system made by samples of Israeli Jewish urban citizens aged 45-74 at two points in time: 1993 and 2000. In 1993, 44% of the population thought that only minor changes were needed; 47% stated that fundamental changes were needed, and 9% thought that the system should be completely rebuilt. In 2000 the respective percentages were 37, 49 and 14%. In the 2 years of the survey, 40% thought the health sector should receive top national priority in government spending. The findings are analyzed with respect to the changes that occurred between 1993 and 2000-in particular, the introduction of the National Health Insurance Law (NHIL) in 1995 and subsequent related legislation. It is argued that while the NHIL has been an important social achievement, its micro-management details and subsequent legislation failed to keep up with the public expectations. Similar changes in public opinion of health systems occurred over the last decade in several other western nations, which reformed their systems. Policy makers should find ways to assure that reforms, which might be necessary for a more efficient allocation of resources from society's point of view, will also respond to the individuals' expectations.

The health care system under French national health insurance: lessons for health reform in the United States

The French health system combines universal coverage with a public-private mix of hospital and ambulatory care and a higher volume of service provision than in the United States. Although the system is far from perfect, its indicators of health status and consumer satisfaction are high; its expenditures, as a share of gross domestic product, are far lower than in the United States; and patients have an extraordinary degree of choice among providers. Lessons for the United States include the importance of government's role in providing a statutory framework for universal health insurance; recognition that piecemeal reform can broaden a partial program (like Medicare) to cover, eventually, the entire population; and understanding that universal coverage can be achieved without excluding private insurers from the supplementary insurance market.

Inequities in health care: a five-country survey

This paper reports the results of a comparative survey in five nations: Australia, Canada, New Zealand, the United Kingdom, and the United States. The survey finds a high level of citizen dissatisfaction with the health care systems in all five countries. Citizens with incomes below the national median were more likely than were those with higher incomes to be dissatisfied. In contrast, relatively few citizens reported problems getting needed health care. Low-income U.S. citizens reported more problems getting care than did their counterparts in the other four countries.

New labour and Britain's National Health Service: an overview of current reforms

Britain's National Health Service (NHS) has been the subject of unprecedented market reforms, which have failed to solve its problems. The New Labour government elected in 1997 has halted the drive toward the marketization of health care and replaced cost with quality as the central concern of NHS administration and policy. Major changes are occurring in the regulation of professional activity, with profound implications for the medical profession and the health service. The authors discuss these changes and possible future problems for the NHS.

Radiology at the turn of the millennium

Herein, the authors (a) review the status of the specialty; (b) report and analyze the various areas in which progress has occurred, namely, conventional radiology and picture archiving and communication systems (or PACS), ultrasonography, computed tomography, magnetic resonance imaging, interventional radiology, and nuclear medicine; and (c) discuss the problems radiology faces as it enters the new millennium. The problems are those facing medicine as a whole, as well as those threatening the future of radiology. These include the following: Will there be a need for radiologists in the future? Will radiology be too costly to be affordable? How can turf wars and fragmentation be solved? Possible remedies are suggested. Positive aspects are discussed in the light of the challenge to demonstrate value. Medical imaging is entering the new millennium with a solid record of recent advances in digital, cross-sectional, and interventional radiology. These advances have made the specialty indispensable in the treatment of patients. Careful statesmanship will be needed to solve the many problems that face medicine as a whole and radiology in particular.

Clarifying the scope of Italian NHS coverage. Is it feasible? Is it desirable?

The reduction in National Health Service (NHS) expenditure as a share of total health care expenditure, the fragmentation of the NHS into 21 regional systems and the implementation of a 'quasi-market' on the provider side of the system has pressed the government to define and specify, in detail, the set of services that are to be guaranteed by the public sector. To understand whether rationing can be more rational and explicit in the Italian NHS, the following are analysed: (i) the new positive list of drugs, as a major example of limiting and making more rational NHS pharmaceutical coverage; (ii) the Di Bella case, as an example of the difficulties of rational policy-making on sensitive issues; (iii) what Italian people think about health care rationing and priority setting (using the 1998 Eurobarometer Survey);( iv) the criteria defining the set of 'essential services' to be guaranteed to all Italian citizens, which are contained in the recently released National Health Plan. The 'revolution' that has taken place in the pharmaceutical sector shows it is feasible to limit, in an explicit and rational way, the extent of NHS coverage. However, the re-classification of the positive list should be regarded as an exceptional event in the history of Italian social policy. The 'Di Bella' case, on the contrary, shows that limiting NHS coverage can be very unpopular, and that the Italian cultural and social context can be unfavourable for the implementation of hard choices. Public attitude toward rationing seems to confirm that Italians are not familiar with rationing issues. Thus, it is very difficult to predict whether the national government will really go ahead with the implementation of a 'list of essential services' and whether this attempt will be successful. Rationing and priority setting should be discussed in the context of a general debate concerning the future of the Italian NHS.

The U.S. healthcare system after NHI: financial ramifications for providers and personnel

Although much attention has been paid to the general structure and possible implementation of a U.S. national health-insurance program, there remains the brass-tacks question of how such a plan would specifically affect today's providers and payers. Here the author outlines some of NHI's financial and organizational implications for patients, facilities, and staff.