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Citizens' Views on Health Care Systems in the 15 Member States of The

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Article  in  Health Economics · March 1997

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 HEALTH ECONOMICS, VOL. 6: 109–116 (1997)

GUEST EDITORIAL

CITIZENS’ VIEWS ON HEALTH CARE SYSTEMS

IN THE 15 MEMBER STATES OF THE
EUROPEAN UNION
ELIAS MOSSIALOS*
The London School of Economics and Political Science

SUMMARY

This paper provides an initial analysis of a Eurobarometer survey on citizens’ views on health care systems which
was conducted in the 15 European Union Member States in 1996. It examines and discusses citizens’ satisfaction
with the running of health care, their views towards major health care reforms and attitudes on health care
spending. © 1997 by John Wiley & Sons, Ltd.

Health Econ. 6: 109–116 (1997)

No. of Figures: 2. No. of Tables: 4. No. of References: 12.

KEY WORDS — health reform; public opinion

INTRODUCTION Managed care in Europe has moved in a

Over the past 10 years there has been a series of
health care reforms in the European Union (EU)
Member States. The reforms were largely a
response to cost containment but also aimed at
making the purchasers and providers of health
services more responsive to the needs of consum-
ers. The response of different governments to
rising health care expenditure has been a series of
ad hoc measures aimed at restraining further
growth and, in some cases, at cost reduction.1
In a number of countries, reforms also aimed at
increasing productivity to reduce the perceived
problems of the public integrated models which
may be associated with waiting lists and lack of
response to patients’ needs.2
number of different directions. These have been
analysed and described elsewhere and will not be
discussed in this paper. There is a consensus that
13 of the 15 EU countries have established overall
health budgets or separate budgets for the main
expenditure components and all countries have
prevented market forces from determining the
level of expenditure.
Against this background it is important to
analyse the views of the public since one of the
main objectives of the reformers was to meet
citizens’ needs.
This paper provides an initial analysis of a
Eurobarometer survey, conducted in the 15 Euro-
pean Union Member States in 1996, on citizens
views on health care systems and spending.

*Correspondence to: Elias Mossialos, Senior Lecturer, Department of Social Policy and Administration, Director LSE Health,
The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK. Tel: 44 171 955 7564, Fax:
44 171 955 6803.

CCC 1057–9230/97/020109–08 $17.50

© 1997 by John Wiley & Sons, Ltd.
110 E. MOSSIALOS
THE ROLE OF OPINION POLL SURVEYS
The measurement of public opinion is relatively
new, it emerged in the 1930s and matured in the
1950s.3 There is still no consensus about the role
of public opinion and the usefulness of opinion
poll surveys in the decision-making process. This
is also the case with opinion poll surveys in the
field of health policy.4
There are certain limitations when relying on a
general single measure, but there are several
reasons to try to draw some preliminary conclu-
sions. First, the comparative study of public
attitudes towards health care issues at European
level has not been extensively measured and
when it happened the surveys did not cover all the
countries of the European Union and sometimes
did not use the same survey methodologies.
Second, it is important to establish a starting
point, in order to establish a trend to take into
account the impact of different reforms and other
changes in the health systems on public opinion. If
a trend has been established, then data could be
used to evaluate changes over a period of time
which may be associated with the introduction of
specific measures or reforms. It is therefore
important to establish this anchor point5 and run
opinion poll surveys on a regular basis in order to
minimize the effects of specific circumstances that
may influence responses.
NEW EVIDENCE ON SATISFACTION
FROM HEALTH SYSTEMS AND SPENDING
ON HEALTH CARE
The data used to examine citizens’ views on
health care come from a cross-national survey.
The survey was part of a Eurobarometer survey
and the design of the questionnaire was done
collaboratively by several researchers, coordi-
nated by LSE Health, including experts in com-
parative health policy and opinion polls. The final
decision concerning the wording of the questions
was that of the Eurobarometer experts. National
sample surveys were conducted in the 15 Member
States of the European Union from 27 February
to 3 April 1996.
Health Econ. 6: 109–116 (1997)
DATA AND METHODOLOGY
The findings of the survey were based on face-to-
face interviews in people’s homes and in the
appropriate national language. Total sample sizes
are as follows: 1025 respondents in Belgium, 1000
in Denmark, 2074 in Germany (1028 in west
Germany and 1046 in east Germany), 1006 in
Greece, 1000 in Spain, 1001 in France, 1004 in
Ireland, 1098 in Italy, 595 in Luxembourg, 1023 in
The Netherlands, 1000 in Portugal, 1354 in the
United Kingdom (1051 in Great Britain and 303
in Northern Ireland), 1053 in Austria, 1000 in
Sweden and 1002 in Finland.
The Eurobarometer survey covers the popula-
tion of the respective nationalities of the 15
European Union Member States, aged 15 years
and over, resident in each of the Member States.
The basic sample design applied in all Member
States was a multistage, random (probability) one.
In each EU country, a number of sampling points
was drawn with probability proportional to pop-
ulation (for a total coverage of the country) and
to population density.6
RESULTS AND ANALYSIS
The Eurobarometer health survey asked Euro-
pean citizens in the 15 Member States a number
of questions related to the running of health
systems in their countries, their views on the need
for reforming the systems and the level of health
expenditures.
The results illustrate a general evaluation of the
National Health System/Service and/or Health
Insurance System without specific reference to
issues such as equity, efficiency and satisfaction
from different levels of care.
The results are presented in Table 1. Figure 1
shows the relationship between the per capita
expenditure on health on the one hand,7 and
satisfaction with the running of health care on the
other. The increase in satisfaction with increasing
per capita expenditure is evident. It is clear that
there is a north–south divide with Ireland and the
United Kingdom falling in between. Satisfaction
in Great Britain is only slightly lower (47.8%)
than that of the total for the United Kingdom
(48.1%) whose average is influenced by the higher
satisfaction rate in Northern Ireland.
Greece, Spain and Portugal show the lowest
© 1997 by John Wiley & Sons, Ltd.
© 1997 by John Wiley & Sons, Ltd.
Table 1. Satisfaction from health systems in the 15 EU Member States in 1996 and per capita expenditure on health in US$ Purchasing Power Parities
in 1993

VIEWS ON HEALTH CARE SYSTEMS IN THE EU

B DK D GR E F IRL I L NL A P FIN S UK EU 15

Very satisfied 10.9 54.2 12.8 1.5 3.7 10.0 9.4 0.8 13.6 14.2 17.0 0.8 15.1 13.1 7.6 8.8
Fairly satisfied 59.2 35.8 53.2 16.9 31.9 55.1 40.5 15.5 57.5 58.6 46.3 19.1 71.3 54.2 40.5 41.5
Neither satisfied nor 19.9 3.8 21.4 27.0 34.0 18.7 17.4 23.1 16.1 8.8 27.6 19.2 7.0 16.7 10.0 19.9
dissatisfied
Fairly dissatisfied 7.2 4.5 9.8 29.7 20.4 12.8 18.2 33.5 7.5 13.6 4.1 37.4 5.3 11.4 25.7 18.8
Very dissatisfied 1.1 1.2 1.1 24.2 8.2 1.8 10.9 25.9 1.4 3.8 0.6 21.9 0.7 2.8 15.2 9.5
Other 1.6 0.5 1.7 0.6 1.8 1.6 3.6 1.3 3.9 1.0 4.5 1.5 0.6 1.9 1.0 1.5
Per capita expenditure 1601 1296 1815 500 972 1835 922 1523 1993 1531 1777 866 1363 1266 1213 NA
on health in US$ PPPs
in 1993

The original question read: In general, would you say you are very satisfied, fairly satisfied, neither satisfied nor dissatisfied, fairly dissatisfied or very dissatisfied with
the way health care runs in (our country)?

Country key: B: Belgium A: Austria F: France

D: Germany FIN: Finland I: Italy
E: Spain UK: United Kingdom NL: The Netherlands
Health Econ. 6: 109–116 (1997)

IRL: Ireland DK: Denmark P: Portugal

L: Luxembourg GR: Greece S: Sweden

111
112
Figure 1. Per capita expenditure on health in US purchasing power parities $ in 1993 and satisfaction from health system.
levels of satisfaction and rank lowest in per capita
health care expenditure. However, the percentage
of those who are neither satisfied nor dissatisfied
in Spain is the highest amongst the EU Member
States (34.0%). On the other hand, Ireland spends
less than Spain and shows a higher level of
satisfaction and Italy spends more than Denmark
and shows the lowest level of satisfaction amongst
all the countries. Denmark shows the highest level
of satisfaction (90%) although health spending is
lower than that of other countries which show a
lower level of satisfaction. The results for Great
Britain show a higher level of satisfaction com-
pared with the 11th report of the British Social
Attitudes Survey8 in 1993 (44%) and a lower level
compared with the King’s Fund survey9 con-
ducted in 1991–92 (66%), where a similar but not
identical question was asked.
Citizens were also asked to express their views
concerning the need for reform of the health
system. The question was similar to that used in
Blendon et al.’s survey in 1988 and 1990 but not
identical.10 Blendon et al.10 surveyed ten countries
including six EU Member States (The Nether-
lands, Italy, West Germany, France, Sweden and
the United Kingdom). The survey was conducted
in six countries in 1990 and the survey in the
United Kingdom was conducted in 1988.
Blendon et al.’s study shows Italy to have the
lowest percentage of respondents (12%), who
believe that only minor changes are necessary to
make the health care system work better. In
contrast, The Netherlands have the highest per-
centage of respondents who believe that only
Health Econ. 6: 109–116 (1997)
E. MOSSIALOS
minor changes are needed (47%), although sup-
port of major changes was also very high (51%) in
this country. It also reveals that having a national
health programme does not equal a guarantee of
high levels of satisfaction.
Blendon et al. argued that the results suggest
that among the countries surveyed, public sat-
isfaction is associated with higher levels of health
care spending per capita. They concluded that this
may be a reflection of the increased availability of
more sophisticated technologies, greater choice of
physicians, less waiting and travel time for elective
and specialized medical procedures, and the age
and modernity of health care facilities.
Table 2 presents the results of the Euro-
barometer survey and Fig. 2 shows the relation-
ship between per capita health care expenditure
and support for fundamental changes or complete
transformation of the system.
The results are compatible with those of the
question on satisfaction. High dissatisfaction is
linked with support for major changes. In the
United Kingdom, however, the percentage of
those asking for major changes or major trans-
formation of the system (56%), 5 years after
reforms were introduced, is much higher than that
of those dissatisfied with the running of health care
(40.9%). The same applies in a number of other
countries (mainly in Belgium, Greece, Spain,
France, Ireland, Italy, Austria and Portugal) where
the percentage of those supporting major reforms
or changes is higher compared with the percentage
of those who are dissatisfied with the health
system. This may reflect a shift in the opinion of
© 1997 by John Wiley & Sons, Ltd.
 VIEWS ON HEALTH CARE SYSTEMS IN THE EU 113

Table 2. Citizens’ attitudes to major health care reforms in the 15 EU Member States in 1996 and per capita
expenditure on health in US$ Purchasing Power Parities in 1996

On the whole, There are some There are some Health care in Other Per capita
health care in good things … good things … (our country) expenditure on
(our country) and minor but only runs so badly health in US$
runs quite well changes would fundamental that we need to PPPs in 1993
make it work changes would rebuild it
better make it work completely
better

B 41.7 34.0 16.5 2.9 4.9 1601

DK 54.4 37.2 5.7 1.8 1.0 1296
D 36.9 38.5 16.7 2.2 5.7 1815
GR 3.8 25.5 44.2 25.0 1.6 500
E 14.1 30.4 34.0 13.5 7.9 972
F 25.6 40.9 24.6 5.0 3.9 1835
IRL 19.4 30.7 25.6 16.9 7.4 922
I 3.4 15.1 43.8 33.1 4.5 1523
L 31.9 43.9 13.3 2.5 8.4 1993
NL 31.0 46.0 17.6 3.5 1.9 1531
A 40.2 33.5 18.0 3.3 5.0 1777
P 3.6 19.4 38.3 31.8 6.9 866
FIN 38.9 51.6 7.7 0.6 1.2 1363
S 28.5 44.1 21.8 3.4 2.2 1266
UK 14.6 27.4 42.0 14.0 2.0 1213
EU 22.1 32.0 29.2 12.2 4.4 NA
15

The original question read: Now, I will read you four statements about the way health care runs in (our country). Which one
comes closest to your own point of view?

Figure 2. Per capita expenditure on health in US purchasing power parities $ in 1993 and public support for fundamental reforms
or complete restructuring of the health system.

those who are neither satisfied nor dissatisfied their views on the need for change. Further
because the question on satisfaction with the analysis of the data will test this hypothesis.
running of health care is more vague compared The present survey shows that support for
with the question which asks citizens to express fundamental changes in the health system or for a

© 1997 by John Wiley & Sons, Ltd. Health Econ. 6: 109–116 (1997)
114 E. MOSSIALOS
complete rebuilding of the system is not sig-
nificant in Germany (18.9%), The Netherlands
(21.1%), France (29.6%) and Sweden (25.2%). It
is apparently very low compared with the results
reported in Blendon et al.’s survey in 1990 (48%)
in West Germany, 51% in The Netherlands, 52%
in France and 64% in Sweden). On the other
hand, in both surveys respondents in Italy and the
United Kingdom appear to be in favour of a
major reform of the system, although the percent-
ages are lower for both countries in the Euro-
barometer survey. In Blendon et al.’s survey 86%
of the Italians and 69% of the United Kingdom
citizens were in favour of a major reform of the
system, whereas in the Eurobarometer survey
the relevant figures were 76.9% and 56%,
respectively.
Regarding the public’s attitude to health spend-
ing, the public offers support for increasing health
expenditure but it opposes raising taxes or health
insurance contributions.
Citizens’ demand for more health spending
differs significantly among the EU Member States
(Table 3). The demand is very high in Greece,
Portugal, the United Kingdom and Ireland, high
in Spain, Italy and Sweden and relatively high in
The Netherlands. In Denmark, Germany, France,
Luxembourg, Austria and Finland the majority of
the respondents would like their governments to
spend the same amount on health. In Belgium,
the largest share of respondents would also like
the government to spend the same amount on
health. Only a small minority of the respondents
were in favour of less governmental spending on
health. The percentage is higher in France
(10.4%), Austria (9.4%), Italy (7.9%) and Ger-
many (6.0%).
Those who favoured increased spending on
health were also asked how the government
should find money for this. The respondents were
given a number of options including raising taxes
and health insurance contributions and spending
less money on other things. Most of the respon-
dents in all EU Member States favoured the
option of spending less on other things which may
indicate tax resistance across Europe with regard
to increased health care spending. However, tax
resistance in the United Kingdom, Sweden and
Denmark was the lowest, although still high, of all
countries surveyed. In the United Kingdom,
Sweden and Denmark only 58.0%, 66.3% and
68.9% of respondents, respectively, who were in
favour of increased health care spending want the
Health Econ. 6: 109–116 (1997)
government to find money by spending less on
other things. In contrast, the relevant percentages
for Belgium, Germany, France and Finland are
93.6, 86.5, 92.9 and 86.0 (Table 4). Opposition to
raising taxes or health insurance contributions is
also very high in all southern EU countries. The
responses in some of these countries may reflect a
general distrust by the public of the government’s
management of resources. Citizens were not
asked whether there were also corresponding
benefits from raising taxes or health insurance
contributions without reducing expenditure on
other things. The responses may have been
different if citizens were asked to indicate in
which sectors governments should contain expen-
diture. Nevertheless, the responses may indicate
that citizens expect efficiency savings in other
sectors and are opposed to tax increases.
CONCLUSION
Our understanding of public opinion on health
care systems can be enhanced by comparing
results of different studies. But instead of seeking
universal conclusions prematurely, more research
is needed to verify, replicate and improve our
knowledge of how different political, economic
and cultural environments affect public opinion.
Previous surveys’ data differ extensively from our
research in measures, sample and time period.
Different results in surveys may reflect differ-
ences in the sampling techniques or the different
contexts in which the same question was asked.
Changes in the wording of questions, even minor,
and the method of interviewing respondents (i.e.
face to face or telephone interview) may also lead
to different results. There are also differences
concerning the sampling methods employed in
different surveys which may affect the results.
The Eurobarometer survey establishes an
anchor point in the EU Member States and
despite a number of methodological problems
and limitations can provide scientists and policy-
makers with useful information on citizens’ views
on health care. Changes in citizens’ views in the
future could be taken into account to measure the
popularity of specific measures or reforms.
Increased dissatisfaction or satisfaction with
health systems may be an indirect indicator of
public disapproval or acceptability of the reforms.
As more and more governments preach that one
© 1997 by John Wiley & Sons, Ltd.
© 1997 by John Wiley & Sons, Ltd.
Table 3. Attitudes to health care spending in the 15 EU Member States (%)

B DK D GR E F IRL I L NL A P FIN S UK EU 15

More 40.6 34.8 25.7 87.1 53.5 32.4 71.0 51.2 33.9 48.5 16.4 79.4 31.8 58.1 81.5 48.0
Same amount 44.4 58.6 53.5 7.3 28.6 49.5 19.3 23.6 52.4 41.7 58.2 12.2 61.7 37.9 14.4 35.9
Less 5.8 2.5 6.0 0.4 1.7 10.4 1.6 7.9 2.7 4.2 9.4 0.8 3.6 1.0 0.8 5.2
Other 9.2 4.2 14.7 5.2 16.2 7.6 8.1 17.3 11.0 5.6 16.1 7.6 2.9 3.0 3.3 10.9

The original wording of the question read: Do you think that the (nationality) government should spend more, the same amount as today or less on health care?

VIEWS ON HEALTH CARE SYSTEMS IN THE EU

Table 4. Attitudes to health care spending in the 15 EU Member States. Responses of those who support that the government should spend more on
health care (%)

B DK D GR E F IRL I L NL A P FIN S UK EU 15

By spending less on 93.6 68.9 86.5 86.4 87.9 92.9 80.1 91.5 80.1 80.2 79.9 85.7 86.0 66.3 58.0 79.7
other things
Health Econ. 6: 109–116 (1997)

By raising taxes or 2.3 17.2 3.5 6.1 2.2 3.8 5.3 2.5 10.2 8.0 5.7 5.8 7.2 22.5 28.8 11.0
health insurance
contributions
Other 4.1 13.9 10.0 7.6 9.9 3.3 14.7 6.0 9.8 11.7 14.4 8.5 6.7 11.1 13.2 9.4

The original wording of the question read: How do you think the government should find the money for this: by spending less on other things or by raising taxes or
health insurance contributions?

115
 116 E. MOSSIALOS
of their aims is to increase consumer choice and
participation, more research is necessary that
focuses on citizens views since the Eurobarometer
survey only provides a general review of the
public’s views on health care. This paper exam-
ined the general trends in each EU Member State.
The initial analysis of the survey draws three
tentative conclusions:
First, the study shows that there is a north–
south divide concerning citizens’ satisfaction with
health care systems, with the United Kingdom
and Ireland being between the two patterns.
Second, satisfaction may be related to higher
spending on health care but there are two
‘extreme’ cases — Italy and Denmark. The case
of Denmark needs further study — a country
which spends only 6.7% of its GDP on health, has
few private beds, a system that is primarily funded
publicly, with a strong emphasis on family practice
and which has achieved significant efficiency gains
in the 1980s and 1990s. It is also worth noting that
dissatisfaction with the health system in Italy was
quite high before the establishment of the NHS11
and continues to be high in all surveys that were
conducted since then.
It may also be the case that because overall
budgets for health services or for part of the
health sector were imposed so late in the day (in
most countries in the mid-1980s), waiting for
appointments with specialists or admission to
hospital are not yet major problems in Belgium,
Germany, France or The Netherlands as they are
in the United Kingdom. There may be, therefore,
a change in the public’s views in the future if
health care in Europe becomes more managed
and if the pace of increasing demand outstrips the
pace of gains from efforts to improve efficiency.
Finally, the public is divided regarding the
attitude to more health spending but it seems that
the majority of those favouring more spending are
opposed to raising taxes or health insurance
contributions and would like governments to
spend less in other sectors.
Should governments base their decision-mak-
ing on the public’s views and attitudes or should
they disregard these views as irrelevant? Govern-
ments need to be aware of the public’s wants and
Health Econ. 6: 109–116 (1997)
View publication stats
needs, but should not be obliged to base their
decision-making on the public’s demand. The use
of scientific evidence on what really works should
be always taken into account in policy formation
and implementation. Public dissatisfaction, if per-
sistent, may indicate that specific measures have
been either ill conceived or badly implemented
and communicated. As R. H. Tawney wrote, ‘The
certainties of one age are the problems of the
next.’12
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