11.1.3.2. Access to healthcare

European governments are concerned with pursuing the efficient and equitable delivery of high quality health services to their populations. Indeed, equitable access to health care, or access based on need and not willingness or ability to pay, is an often stated goal of publicly-funded health systems. It is, therefore, important to consider not just health system efficiency, but also the distribution of financial burden across income groups and the distribution of health care use and accessibility i.e. to what extent are there variations in the accessibility or utilization of health services by factors unrelated to need, such as income, region, and socio-economic status? The precondition of access to care is coverage by health insurance. Universal, or near universal, coverage of the population by the statutory for a comprehensive basket of health services has been achieved in all European countries. However, even when near universal coverage is achieved, there still may be barriers to access that deter or prevent individuals from seeking care (Gulliford et al 2002).

Access to care is also contingent upon financial factors, such as the degree of cost sharing in the system. In much of Europe, many health care services are free at the point of use, and in those countries that do rely on cost sharing arrangements, extensive protection mechanisms are in place to reduce or remove the financial burden from those not, or less, able to pay (Mossialos and Thomson 2003) (see Section 11.6 on Financing health care). Organizational factors such as waiting times, and geographical factors including the distribution of services and individuals’ mobility also have an impact on accessibility. A recent cross-national OECD project on waiting times identifies European countries with significant waiting times problems as: Denmark, Finland, Ireland, Italy, the Netherlands, Norway, Spain, Sweden and the United Kingdom (UK); and those without as: Austria, Belgium, France, Germany, Luxembourg and Switzerland (Siciliani and Hurst, 2004). While waiting times represent a significant barrier to access, in particular for elective and specialised procedures, there is little evidence on differential experiences of waiting times across population groups, e.g. socio-economic groups. However, there is evidence to suggest that the availability of a private alternative to the public system may allow higher income groups with private insurance to access certain services more quickly than those without this additional coverage (Mossialos and Thomson 2004; Colombo and Tapay 2004).

It is important also to recognize the role of personal factors that influence an individual’s propensity to seek health care (Gulliford et al 2002). Educational attainment, awareness of available services, knowledge of and ability to articulate one’s symptoms as well as cultural influences may facilitate or hinder access to care. Knowledge limitations can affect some population groups where eligibility to receive health care requires participation in an administrative procedure or some other form of conditionality. In Austria for example, unemployed people may be unaware that coverage by the public system relates directly to their appearance at a job centre, and that failure to appear will lead also to a failure to be eligible to receive care. This type of problems appear limited to health systems funded mainly by social health insurance, and in particular to those where entitlement may be automatic but eligibility depends upon fulfilling certain administrative requirements.

Studies measuring equity in the use of health services tend to show a disproportionate distribution of utilization favouring certain population groups, such as higher income earners, which is indicative of inequity and barriers to access for some vulnerable groups. More specifically, the levels of inequality in utilization after standardizing for need differences has been compared across countries, and reveals that inequity exists even among countries with universal coverage and largely publicly funded health system. Specifically, while there is little evidence of inequity in GP visits in most countries, or the distribution of GP visits is pro-poor, there is evidence of significant pro-rich inequity in the use of specialist care in most countries (van Doorslaer et al, 2004). Based on the European Community Household Panel survey, the only countries with pro-rich inequity in primary care are Finland and Portugal, with many countries showing pro-poor inequity: Spain, Greece, Austria, Germany, the Netherlands for the probability of a GP visit, and many more when considering total number of GP visits in a year. For specialist services, however, most countries show pro-rich inequity, with the highest levels of inequity favouring the wealthy population groups again in Portugal and Finland, but also in Ireland, Italy, Spain, Norway and Denmark (for number of visits) (van Doorslaer et al, 2004). Portugal also appears to have the highest level of pro-rich inequity in the probability of hospital inpatient care among the ten European countries investigated (with little evidence of inequity in the other countries) (Masseria et al 2004). A recent study of inequity among the over-50 population included in the Survey of Health, Ageing and Retirement in Europe (SHARE) supports the above findings, showing the likelihood of a physician visit disproportionately in favour of higher income and wealthier individuals in about half of the 11 European countries included in the survey, with a consistent pro-rich inequity found in dental care (Allin et al 2008).

Another important issue to be noticed relates to assumptions stating that that health status is an adequate measure of health care need or that health care utilization can approximate access. Indeed, measuring need for health care has been much-debated in particular because it does not consider the capacity of an individual to benefit from health care (Culyer and Wagstaff, 1993). Although health status as an indicator of need is the most commonly used indicator -,mainly because it can be measured through surveys - also the different principles of equity are the subject of debates (Oliver and Mossialos, 2004). Equal access (for equal need) may not necessarily mean the same thing as equal treatment or utilization (Mooney et al, 1991; Culyer et al, 1992; Mooney et al, 1992) (Goddard and Smith 2001). These two concepts of equity are arguably of less importance than the goal of equal health outcomes. Though there is evidence of inequity in access and utilization of health care, the persistent, and perhaps widening, health inequalities are also evident. Ensuring equal access to health care may arguably be one means to reduce health inequalities. Many countries have introduced programmes to improve access with this aim, though it is likely that interventions that extend beyond the provision of health care services are more effective (Mackenbach and Bakker 2002). See also Section 11.4.2 Public Health Services).