Health system characteristics and unmet care needs in Europe: an analysis based on EU-SILC data

Abstract

Using survey data from the 2009 wave of the European Union Statistics on Income and Living Conditions, this study examines the determinants of unmet needs for medical and dental care in European countries. Special emphasis is put on the impact of health system characteristics. Four factors are taken into account: the density of doctors or dentists, the rules governing access to practitioners, the method of paying primary care physicians, and the amount of out-of-pocket payments. The analysis is carried out using multilevel logistic regression models. Separate regressions are estimated for medical and dental services. The dependent variable is whether respondents reported that, at least once in the last 12 months, they needed care but did not receive it. The estimation results show that the probability of experiencing unmet medical or dental needs varies noticeably across countries. This inter-country variability seems to be partly explained by the differences in the financing of health care. Indeed, a positive link is found between the share of households' out-of-pocket payments in total health expenditure and the probability of unmet needs. The other contextual factors do not seem to play a significant role.

Out-of-Pocket Payments and Subjective Unmet Need of Healthcare

“…A second element worth noting is that, even in countries with (near) universal insurance and relatively low OOP payments, there remains a substantial fraction of the population that reports postponing or forgoing healthcare [13][14][15][16][17][18]44]. The same is true in countries with relatively high OOP payments but an elaborate system of social protection for the poor, an example being Belgium, in which the total amount of co-payments is subject to an income-related cap [68].…”

“…In the less extreme case of countries with (almost) universal coverage (or of the insured individuals in the USA), OOP payments will have an influence on unmet need for individuals with high morbidity (and a high level of utilization of healthcare) if the insurance system reimburses only a fraction of a treatment or medicine. Taking due account of the caveats needed for international comparisons of the level of SUN, it is still interesting to note that the most important explanation for systematic differences in SUN between countries seems to be the share of OOP payments in total healthcare expenditure (with EU-SILC data [13,14] and with SHARE data [15]). In fact, SUN due to financial reasons has also occurred in very rich countries (Sweden [16], Canada [17] and privately insured populations in the USA [18]) as soon as OOP payments started to increase.…”

“…One of the main factors contributing to this postponement is the amount patients pay out of pocket (OOP) at their point of access to the system: doctors' fees, cost of medicines or glasses, hospital bills [13]. We present a critical review of the literature on the impact of OOP payments on subjective unmet healthcare needs.…”

“…Many surveys have introduced subjective indicators of postponing or forgoing needed healthcare and have related it to different causes [2,[13][14][15]39]. One of the main factors contributing to this postponement is the amount patients pay out of pocket (OOP) at their point of access to the system: doctors' fees, cost of medicines or glasses, hospital bills [13].…”

Do We Reap What We Sow? Exploring the Association between the Strength of European Primary Healthcare Systems and Inequity in Unmet Need

“…This effect occurred only among the disadvantaged population in a European country, and among the more wealthier population groups. The scarce literature available identifies low income as one of the strongest predictors of experiencing unmet need [21, 27, 28]. Receiving an adequate income is essential to being able to purchase healthcare and is vital for obtaining access to PC and specialist care.…”