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Centre d'Etudes de Populations, de Pauvreté et de Politiques Socio-Economiques
International Networks for Studies in Technology, Environment, Alternatives and Development
IRISS Working Papers
IRISS Working Paper Series
IRISS-C/I
An Integrated ResearchInfrastructure in theSocio-economic Sciences
2007-14 November 2007
Self-Assessed Health Status and Satisfaction withHealth Care Services in the Context of the EnlargedEuropean Union
by
Livia Popescu
Cristina Rat
Adina Rebeleanu-Bereczki
1
brought to you by COREView metadata, citation and similar papers at core.ac.uk
Centre d'Etudes de Populations, de Pauvreté et de Politiques Socio-EconomiquesInternational Networks for Studies in Technology, Environment, Alternatives and Development
Self-Assessed Health Status and Satisfaction with Health Care Services in theContext of the Enlarged European Union
Livia PopescuFaculty of Sociology and Social Work, Babes-Bolyai University Cluj-NapocaCristina RatFaculty of Sociology and Social work, Babes-Bolyai University Cluj-NapocaAdina Rebeleanu-BereczkiFaculty of Sociology and Social work, Babes-Bolyai University Cluj-Napoca
Abstract The paper aims at analysing the relationship between self-rated health-status, satisfaction with healthcare services and socio-economic factors, in the context of different national health care systems in the enlargedEuropean Union. The effects of socio-economic deprivation and the functioning of national health care systems onself-rated health status and satisfaction with health care services are investigated using the European Social Sur-vey 2006 dataset (ESS3), and macro data provided by Eurostat (2007) and the World Health Organization (2007).Socio-economic deprivation is measured both at the micro-level (using indicators of economic strain, household in-come, education, employment status and belonging to discriminated groups), and the macro-level (national povertyrates, the values of poverty thresholds, quintile ratios and GDP per capita). The performance of national healthcare systems is quantified with the help of two indexes, designed for the purpose of the present study: an indexof total health care provisions and an index of governmental commitment to health care. The following countriesare included in the analysis: Belgium, Bulgaria, Denmark, Finland, France, Germany, Hungary, Poland, Portugal,Romania, Slovenia, Slovakia, Spain, Sweden, and the United Kingdom.
Reference IRISS Working Paper 2007-14, CEPS/INSTEAD, Differdange, Luxembourg
The views expressed in this paper are those of the author(s) and do not necessarily reflect views ofCEPS/INSTEAD. IRISS Working Papers are not subject to any review process. Errors and omissions are the sole
Regidor, R., Calle M.E., Navarro, P., Dominquez, V. (2003), “Trends in association
beween average income, poverty and income inequality and life expectancy in Spain”,
Social Science and Medicine, Vol. 56, pp 961-971.
Rico, A. et al (2004), “Organizational Restructuring in European Health Systems: The
Role of Primary Care”, in Taylor-Gooby, P. (ed), Making a European Welfare State?
Convergences and Conflicts over European Social Policy, Oxford: Blackwell Pub., pp. 53-
69.
Appendix
Table A.1: Comparing 2006 survey data
on the relative frequency of self-rated bad health
Eurobarometer
2007
(Fieldwork: Oct.-
Nov. 2006)
European Social
Survey, 3rd
round,
2007 (Fieldwork:
Jun.-Jul. 2006)
Belgium 5 4.3
Bulgaria 14 16.5
Cyprus 5 4.9
Denmark 6 5
Finland 6 4.1
France 6 7.2
Germany 7 10.1
Hungary 15 18.4
Poland 12 11.4
Portugal 9 15.5
Romania 10 17.6
Slovakia 8 10.8
Slovenia 7 10.8
Spain 7 11.3
Sweden 6 4.8
UK 8 7.5
Sources: Eurobarometer, Health in the European Union, September, 2007
European Social Survey, October 2007. Figures indicate the percentage of respondents who declared that
their health is bad or very bad. For inter-survey differences higher than 2.5%, the cells were shaded.
Table A.2: Country-level indicators of total health care provisions
and national values of the index
Total
expenditures
on health as %
of GDP (2004)
Per capita total
expenditures on
health at
international
dollar rate
(2004)
Hospital beds/
10000
population
(2004 or 2005)
Physicians
per 1000
persons
(2003-2004)
Index of total
health care
provisions
Belgium 9.7 3133 53 4.49 2.34
Bulgaria 8 671 64 3.56 -0.98
Cyprus 5.8 1128 34 2.34 -4.76
Denmark 8.6 2780 38 2.93 -0.76
Finland 7.4 2203 70 3.16 0.05
France 10.5 3040 75 3.37 3.32
Germany 10.6 3171 84 3.37 4.05
Hungary 7.9 1308 79 3.33 0.27
Poland 6.2 814.1 53 2.47 -3.52
Portugal 9.8 1896.9 37 3.42 -0.45
Romania 5.1 432.7 66 1.9 -4.21
Slovakia 7.2 1061 69 3.18 -1.14
Slovenia 8.7 1815 48 2.25 -1.44
Spain 8.1 2099 35 3.3 -1.61
Sweden 9.1 3532 52 3.28 1.35
UK 8.1 2560 39 2.3 -1.69
Source: World Health Statistics – the 2007 Report of the World Health Organization.
The index of total health care provisions was constructed as the simple additive index of the for
standardized indicators (sum of Z-scores).
Table A.3: Country level indicators of governmental commitment to health care
and national values of the index
General
government
expenditure on
health as % of
total expenditures
on health (2004)
Out-of-pocket
expenditures as %
of total private
expenditures on
health (2004)
Per capita general
government
expenditures on
health at
international
dollar rate (2004)
Index of
governmental
commitment
to health care
Belgium 71.1 83.5 2228 0.47
Bulgaria 57.6 98 386 -3.93
Cyprus 44.3 93.4 499 -5.61
Denmark 82.3 81.3 2287 1.7
Finland 77.2 80.8 1700 0.57
France 78.4 34.9 2382 0.21
Germany 76.9 57.5 2440 0.85
Hungary 71.6 88 937 -0.8
Poland 68.6 89.6 558.8 -1.61
Portugal 71.6 79.4 1358.8 -0.33
Romania 66.1 93.4 286 -2.36
Slovakia 73.8 73.1 782 -0.73
Slovenia 75.6 39.5 1372 -0.44
Spain 70.9 81 1488 -0.28
Sweden 84.9 92 3000 3.28
UK 86.3 90.5 2209 2.61
Source: World Health Statistics – the 2007 Report of the World Health Organization.
The index of governmental commitment to health care services is the additive index of the standardized
general governmental expenditures on health as % of total expenditures on health, the standardized per
capita general expenditures on health, and the negative of the standardized out-of-pocket expenditures
as % of total private expenditures on health, weighted by the standardized share of private expenditures
as % of total expenditures on health.
Table A.4: Country-level indicators of poverty and income inequality
Poverty
threshold in 1000
EURO (2005)*
Poverty rate
(2005 )
Quintile
ratio (2005)
GDP/Capital in
1000 PPS
(2005)
Belgium 18.8 15 4.1 27.6
Bulgaria 1.8 15 4 7.4
Cyprus 16.4 16 4.3 19.6
Denmark 19.4 13 3.5 28.9
Finland 16.7 12 3.5 19.6
France 18.1 13 4 25.5
Germany 19.3 13 4.1 25.3
Hungary 7.8 13 4 14.5
Poland 5.6 21 6.6 11.6
Portugal 9.9 20 8.2 16.6
Romania 1.4 18 4.9 7.8
Slovakia 7.5 13 3.9 12.7
Slovenia 12.8 12 3.4 18.9
Spain 15.2 20 5.4 22.9
Sweden 17.9 9 3.3 27.7
UK 20.5 19 5.6 27.1
* Note: Poverty threshold computed for the annual income of a family composed of two adults and two
dependent children at 60% median income per equivalent household member using the OECD-2
equivalence scale.
Source: For EU-25 data was provided by the 2007 Joint Report on Social Inclusion of the European
Commission. For poverty rates, see Annex 1C, p.140. For the values of the poverty threshold, see Table 5,
p. 18. For Bulgaria and Romania, poverty thresholds were estimated on the basis of data from the latest
National Reports on Social Inclusion (2006).
Table A.5: The probability of reporting bad health and average satisfaction with the
health care services in the country (European Social Survey, 3rd
Round, 2006)
Reporting bad or
very bad health (%
of population)
Average
satisfaction with
health care services
in the country
Belgium 4.3 7.35
Bulgaria 16.5 2.56
Cyprus 4.9 6.19
Denmark 5 6.16
Finland 4.1 6.96
France 7.2 6.22
Germany 10.1 4.39
Hungary 18.4 3.29
Poland 11.4 3.85
Portugal 15.5 3.57
Romania 17.6 3.76
Slovakia 10.8 3.93
Slovenia 10.8 5.17
Spain 11.3 6.02
Sweden 4.8 5.84
UK 7.5 5.25
Source: European Social Survey, 3rd
Round, 2006. Own calculations.
Methodological Note 1: Estimating income per equivalent household member based
on declared household income category
The original international ESS3 dataset does not contain micro-level data on the overall
income of respondents’ households. Respondents were asked to rank their household
into an income categories printed on the response-cards. For each country, there were
12 income categories. However, in the case of Hungary and Romania, income data was
not comparable (the income-intervals were different). Therefore the original country-
specific household income variables (hinctnro and hinctnhu) were added to the
international dataset.
Based on the income category (ordinal variable hinctn), the overall income of the
household was estimated at the middle of the income interval (EUROS/month). In the
case of the highest income category, the average difference between categories was
added to the lower limit of the interval. Unlike for the other states, in Hungary there
were 13 income categories, in HUF. Averages were therefore converted in EURO. The
estimated overall income of households calculated in this manner is presented in the
following table:
Table A.6: Estimating overall household income Approximate
MONTHLY INCOME
New
value
Approximate
MONTHLY INCOME
New
value
Approximate
MONTHLY INCOME
New
value
Show
card
FOR EU-15 and Bulgaria For Romania
(data in €)
For Hungary
(in 1000 HUF)
1000
HUF
Euro*
J Less than €150 €75 Less than €100 €50 Less than 37 18.5 €74
R €150 to under €300 €225 €100 to under €200 €150 37 to under 56 46.5 €185
C €300 to under €500 €400 €200 to under €300 €250 56 to under 75 65.5 €260
M €500 to under €1000 €750 €300 to under €400 €350 75 to under 100 87.5 €348
F €1000 to under €1500 €1250 €400 to under €500 €450 100 to under 125 112.5 €447
S €1500 to under €2000 €1750 €500 to under €600 €550 125 to under 150 137.5 €546
K €2000 to under €2500 €2250 €600 to under €700 €650 150 to under 175 162.5 €646
P €2500 to under €3000 €2750 €700 to under €800 €750 175 to under 200 187.5 €745
D €3000 to under €5000 €4000 €800 to under €900 €850 200 to under 225 212.5 €844
H €5000 to under €7500 €6250 €900 to under €1000 €950 225 to under 300 262.5 €1043
U €7500 to under €10000 €8750 €1000 to under €1100 €1050 300 to under 375 337.5 €1341
N €10000 or more €10500 €1100 or more €1150 375 to under 500 437.5 €1739
- - - - 500 or more 625 €2484
Note: *For Hungary, national currency was converted into Euro at the 01.01.07 exchange rate, 1 Euro=251.63 HUF.
In order to account for household size and structure, the OECD-2 equivalence scale was
used and household income per equivalent adult was computed. This measure served as
the indicator of “objective” household income: declared income per equivalent
household member. The three variables (estimated income for the EU countries and
Bulgaria, estimated income for Romania and Hungary) were merged into one variable.
The following table presents the number of valid cases for each country (N), average
estimated income per equivalent household member and standard deviations for each
country.
Table A.7: Estimated income per equivalent household member
Country Mean
(Euro)
Number
of valid
cases
Std. Deviation
(Euro)
Belgium 1480.7 1559 965.8
Bulgaria 120.7 1128 88.2
Cyprus 1130.8 811 687.4
Germany 1478.6 2173 1005.1
Denmark 2143.1 1327 1199.9
Spain 1124.2 1127 1032.9
Finland 1652.9 1724 989.5
France 1484.5 1740 1035.0
United Kingdom 2062.7 1858 1580.9
Hungary 303.0 1274 150.1
Poland 356.4 1390 457.1
Portugal 784.8 1212 982.5
Romania 141.8 1946 114.1
Sweden 1770.4 1781 969.1
Slovenia 700.5 1166 462.7
Slovakia 434.6 1063 484.6
Total 1138.0 23279 1125.8
Methodological Note 2: Minority status and subjective feeling of belonging to a
discriminated group: illustration for Eastern European countries
The dataset does not allow the identification of respondents in terms of ethnicity,
nevertheless, it contains information on ethnic minority status and belonging to a
discriminated group in the country (subjective assessment on discrimination).
The following table presents on a country-level the frequencies of reporting belonging
to discriminated groups, as well as on what grounds does discrimination occur, in the
opinion of respondents.
TABLE A.8: Percentages of respondents who considered themselves as belonging to
discriminated groups Bulgaria Hungary Poland Romania Slovakia
Number of respondents who
reported to belong to a
discriminated group (%)
101
(7.4%)
76 (5.0%) 85
(4.9%)
103
(4.8%)
110
(6.2%)
Discriminated on grounds of… (%)
Colour or race 11.9 31.6 - 13.6 23.6
Nationality 10.9 14.5 2.4 12.6 17.3
Religion 5.0 6.6 8.2 5.8 6.4
Language 7.9 1.3 - 1.0 9.1
Etnicity 47.5 28.9 - 17.5 22.7
Age 23.8 7.9 17.6 21.4 22.7
Gender 7.9 3.9 9.4 2.9 16.4
Sexuality 1.0 1.3 - 3.9 0.9
Disability 8.9 14.5 23.5 9.7 9.1
Other 8.9 30.3 45.9 4.9 9.1
Don’t know 8.9 1.3 2.4 8.7 1.8
No answer - - - - 4.5
Source: ESS3 dataset. Own calculations. Multiple responses were possible (i.e. cumulative percents
exceed 100%). Figures indicate relative frequencies of responses. For example, in Romania, out of the 103
persons who considered themselves to belong to discriminated groups, 13.6% declared that they are
discriminated on grounds of their colour or race, 12.6% that on grounds of their nationality, etc.
Ethnic minority status was accompanied by the feeling of belonging to discriminated
groups at a different rate, depending on the country of residence:
TABLE A.9: Feelings of belonging to discriminated groups (%) Bulgaria Hungary Poland Romania Slovakia
% of respondents belonging to an
ethnic minority
25.9% 40.5% 13.0% 15.0% 28.8%
% of respondents belonging to the
majority ethnic group in the
country
4.0% 3.0% 5.0% 3.9% 4.2%
Source: ESS3 dataset. Own calculations. For example, in Romania, 15% of those declaring to belong to a
minority ethnic group in the country declared that they also belong to a discriminated group. Out of those
who belong to the ethnic majority group (Romanians), 3.9% declared that they belong to a discriminated
group.
Table A.10: Inequalities in self-assessed health by socio-economic position as reported
by Mackerbach, Meerding and Kunst (2007)
Country Year Odds ratios
Men Women
Belgium 1997 3.22 2.36
Bulgaria 1997 2.19 2.84
Denmark 1994 2.16 3.00
Finland 1994 2.99 3.29
France (*occupation) 1991-92 2.24 No data
West Germany 1990-91 1.76 1.91
Great Britain 1996 3.88 3.92
England (*income) 1995 3.08 2.66
Italy 1994 2.94 2.55
Spain 1997 2.58 3.10
Sweden 1997 2.37 3.06
Source: Mackerbach, Meerding and Kunst (2007: 28). Data presented only for selected countries. The
indicator of socio-economic position was education, unless otherwise stated in parentheses. Poland was
omitted due to the high difference between the results of the two surveys cited by the authors.
i In the conceptual model of the relationship between health development and social and economic
career developed by Mackerbach et.al. (2007) health in childhood influences educational level, which in
turn affects health in early adulthood. The latter influences labor market participation and job position,
which mark health status in the early middle-age. Being healthy in one’s early middle age determines to a
large extent personal earnings and household wealth, which will affect health in late middle-age. (see
Mackerbach et.al. 2007: 80). ii For self-reported health status, Mackerbach et.al. used mostly national survey data from 1990-97 (see
Mackerbach et.al., 2007:28). iii
Event the recent report by Busse, Wörz, Foubister, Mossialos and Berman (2006) on cross-country
differences in access to health care services does not include Bulgaria and Romania due to the lack of
reliable data. iv Differences between ESS 3
rd Round (2006) and Eurobarometer 272e (2006) findings with respect to the
self-assessed health are presented in the Annexes, Table 1. They show that such limitations do exist. v The number of physicians per 1000 persons is used as a proxy for access to health care services by
Eurostat (see European Statistical Pocketbook, Eurostat, 2005). vi For a recent report on health-status and access to health care services among the members of the Roma
ethnic minority see European Roma Rights Centre (2006).
Centre d'Etudes de Populations, de Pauvreté et de Politiques Socio-EconomiquesInternational Networks for Studies in Technology, Environment, Alternatives and Development
IRISS Working PapersThe IRISS Working Paper Series has been created in 1999 to ensure a timely dissemination of the research outcomefrom the IRISS-C/I programme. They are meant to stimulate discussion and feedback. The working papers arecontributed by CEPS/INSTEAD resident staff, research associates and visiting researchers.
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