Patient satisfaction and health system responsiveness in a decentralised health system

Abstract

Evaluating the effectiveness, equity, and efficiency, along with the patients' perspective, can help identify potential shortcomings and improve the performance of health services. This PhD thesis aims to evaluate the determinants of healthcare quality from the patients' perspective, while also examining potential sources of socioeconomic inequalities in a universal and decentralized healthcare system such as the Spanish National Health System (SNHS). The research questions are addressed in three chapters. In the first chapter, the drivers of satisfaction with the Spanish Health System are explored. Using extensive longitudinal and cross-sectional data for Spain, we observe that policy measures such as public health spending and the patient-doctor ratio have a significant impact on the quality of healthcare systems, beyond individual-level differences. Our findings indicate that policymakers must exercise caution when reducing the level of health resources, particularly health personnel, as a response to economic downturns. Additionally, our research provides evidence that a growing reliance on private healthcare may be a reflection of inefficiencies in the public system, or the existence of important features of private insurance that are valued by patients. The second chapter identifies the key determinants of prompt attention, one of the key health responsiveness domains and one of the most important determinants of health system satisfaction. Specifically, this study test whether waiting times for primary and specialist care depend on patients´ socioeconomic status (SES) in Spain. Additionally, we utilize the continuous nature of our data to investigate if the SES-related disparities in waiting times for specialist consultations vary across different parts of the waiting time distribution. Our analysis indicates the existence of a SES gradient in waiting times for specialist services that can be attributed to factors such as education, employment status, and income. Additionally, we observe a less pronounced SES gradient for primary care, mostly associated with employment status. While the quantile estimates demonstrate the presence of a SES gradient throughout the distribution of waiting times for specialist visits, the SES differences are less pronounced in the context of longer waiting times in the public sector, although they still persist. Our findings suggest that the principle of equal treatment for equal need is not being implemented in practice. The third chapter focuses on the role of political identity in influencing the demand for private health care (‘political demand for health care’). We exploit evidence coming from the regional variation in the 2012 austerity cuts in the Spanish National Health System (NHS). Our findings suggest that individual support for congestion or right-wing narratives increased demand for private healthcare in areas where health services were more exposed to austerity spending cuts. These effects are stronger among relatively more affluent and healthier individuals, consistent with a ‘congestion narrative’ which prompts individuals to seek care beyond the National Health System. The findings of this thesis may assist policy-makers and managers in monitoring the performance of health systems by offering evidence-based policy recommendations. This consideration is of particular interest in view of the fact that health systems in many countries must address a growing public-sector deficit, respond to increasing pressures due to COVID-19, and demographic shifts like an aging population and increasing polarization, which render the implementation of evidence-based health policies more demanding.