Self-Assessed Health Status And Satisfaction With Health Care Services In The New Members States Of The European Union

L’article presente les predicteurs socio-economiques de l’etat de sante auto-evaluee ainsi que de la satisfaction envers les services medicaux dans cinq pays de l’Europe Centrale et Orientale: la Bulgarie, la Hongrie, la Pologne, la Roumanie et la Slovakie. L’analyse est fondee sur les micro-donnees fournies par le European Social Survey realise en 2006. Pour mieux saisir les differences existantes entre les systemes nationaux de sante, les auteures ont construit deux indices: l’index de l’ensemble des services medicaux et l’index de l’engagement gouvernemental pour les soins de sante. Les deux indices synthetisent les indicateurs macro, fournis par le World Health Report de 2007. Au niveau de la comparaison entre les pays, l’analyse temoigne d’une correspondance forte entre la probabilite de declarer une mauvaise sante, la satisfaction moyenne avec les services medicaux et l’engagement gouvernemental pour les soins de sante. Les performances des cinq pays etudies et particulierement de la Bulgarie, sont faibles sur toutes les dimensions de l’analyse, notemment en les comparant a la moyenne de l’EU-15. Le fait de declarer d’etre en mauvaise sante et d’etre insatisfait des soins de sante ont des determinants socio-economiques similaires. L’effet le plus important appartient au revenu du menage et a l’appartenance aux groupes discrimines. Introduction: Health Care Reforms and Health Status in CEE Countries During the first decade of transition, all Central and Eastern European (CEE) countries moved from centralised health care systems with universal coverage to insurance-based systems. They confronted the need to improve the quality of services, decentralize responsibilities related to health care, contract-out services and, at the same time, reduce public expenditures on health care. One of their main concerns was thus to limit the attributions of the state and introduce market forces in the health sector.  The article is based on independent research carried out by the authors at CEPS/INSTEAD Luxembourg, within the framework of the IRISS research program financed by the European Commission and the ECHISERV research project financed by the Romanian Ministry of Education and Research through the grant CEEX 157/2006. The reforms of the health systems throughout post-socialist Europe had ambitious objectives and created high expectations which could hardly be met. The shift from a Beveridge-type universal, residence-based health care system to an insurance-based Bismarckian system was envisaged to improve the efficiency of the management of the public health care fund, and strengthen personal responsibility for the protection of one’s good health. However, contributions to the health care fund were difficult to collect and revenues were often scarce. This situation increased the demand for budget subsidies (Ringold, 1999). The burden of healthcare costs shifted to the patients as co-payments or informal payments in the public system, or as out-of-pockets expenditures in the private system. As compared to the OECD countries, where private sickness insurance accounts for around a quarter of total expenditures on health care, in post-socialist countries this share is negligible (OECD, 2004). The 2002 GVG study on the 13 candidate countries to EU accession emphasizes that the failure of health system reforms has multiple causes, but the most salient ones were either generated by the macroeconomic environment, or rooted in the design and the functioning of health insurance schemes. The reforming strategies did not overcome past deficiencies such as the excessive utilization of hospital care and the underdevelopment of primary care (GVG, 2002). In her analysis of the Hungarian healthcare reform, Ferge (1991) is highly critical with respect to lack of transparency in the decisions making process. The author states that the main actors of the reform (the government, the medical agencies and the high-status groups in the society) monopolized the public discourse and presented a unilateral perspective on the reform, highlighting the advantages (their advantages) and omitting the shortcomings. Their options have been convergent, leading to the implementation of a specific health insurance model. Arguments against modifying the structure of the healthcare system in Romania have been presented by Marginean (1995), who emphasized that one of the risks is the exclusion of certain categories of the population from public health care benefits. Other experts consider that the fragmented collection of funds hinders the efficiency of their administration (GVG, 2002). The quality of services remained low, and informal payments still constitute rather the rule than the exception (Rebeleanu, 2007). The access to health care services is uneven or limited although many non-contributing persons have the equivalent status of “insured”: family members, children, students, unemployed and beneficiaries of the Minimum Income Guarantee, who are covered by other social protection schemes. In 2000, when the new health insurance system actually started to work, 25% of the population was not covered by the health insurance (World Bank, 2003). The proportion was much higher among the Roma population, in rural areas, and in the case of low educated persons (World Bank, 2003). The financial crisis from the health care system is another recurrent concern of studies on the Romanian health care system (see Popescu, 2004; Rebeleanu, 2007). For all five CEE countries included in the present analysis, namely Bulgaria, Hungary, Poland, Romania and Slovakia, expenditures on health care as percent of GDP were in 2004 below 8%, the average for OECD countries. In the case of Romania, the share was 5.1%, which is lower than in the case of the other EU accession countries (see Figure 1). Figure 1: The evolution of total expenditures on health as % of GDP in CEE countries