Public Perceptions of the Factors That Constitute a Good Healthcare System Joshi V D, Chen Y M, Lim J F Y
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Original Article Singapore Med J 2009; 50(10) : 982 Public perceptions of the factors that constitute a good healthcare system Joshi V D, Chen Y M, Lim J F Y ABSTRACT system. Further snapshot surveys to assess Introduction: In Singapore, few studies have perceptions of the healthcare system should been done on the factors that the general public be conducted with questionnaires abridged to considers to be most important in the healthcare include only these five identified critical factors. system. We conducted this pilot study to determine the factor structure, reliability and Keywords: healthcare system, Singapore validity of statements in a healthcare survey healthcare system questionnaire as predictors of public perception Singapore Med J 2009; 50(10): 982-989 of a good healthcare system. IntrodUction Methods : Data on public perceptions of The expectations of the public to receive the “best possible healthcare from a national survey of 1,434 adult care” in the developed country setting is increasingly Singaporeans was analysed using a principal tenuous, given the competing and often conflicting component analysis and regression, to obtain demands on the finite resources available in healthcare.(1) the factors and predictors. The survey employed While governments the world over are facing increasing 31 statements on healthcare quality, cost, access challenges of providing high quality and financially and the role of the individual vis-à-vis society, sustainable public healthcare, public expectations of which participants ranked on a five-point Likert better health and better healthcare are also rising, driven scale. by the spread of information, growing political and economic empowerment, and aggressive marketing by Results: The exploratory factor analysis identified pharmaceutical and medical device manufacturers.(2) six critical factors (F): National healthcare Furthermore, it is naïve to assume a “one size fits all” Singhealth Centre financing framework (F1), Service at public perspective of what society desires from its healthcare for Health Services Research, institutions (F2), Service at private institutions system and to apply research and findings from different Singapore Health Services Pte Ltd, (F3), Individual responsibility for health (F4), countries with different societal norms and expectations 226 Outram Road, Affordability at public institutions (F5), and brusquely into any given health system. The plurality Block A, #03-01, Affordability at private institutions (F6). These of the healthcare delivery and financing systems in the Singapore 169039 factors explained 54 percent of variance, and world suggests powerful and highly conceptualised Joshi VD, MSc, PhD Cronbach’s alpha ranged from 0.5 to 0.72, except Research Fellow social influences on the healthcare system, and it has now for F1. Regression analysis showed an association become essential to carefully study consumers’ needs Lim JFY, MBBS, MPH, MRCSE of public perception of good healthcare in and expectations locally, to determine the appropriate Director, Research and Education Singapore with the following factors: F2 (odds allocation of healthcare resources. ratio [OR] 1.79, 95 percent confidence interval Healthcare systems are typically discussed in Department of Biostatistics, [CI] 1.48–2.16, p-value is less than 0.0001); F3 (OR academia, based on the consideration of cost, quality Singapore Clinical Research Institute 1.29, 95 percent CI 1.10–1.52, p-value is less than and access. This is a useful conceptual framework, but it Pte Ltd, 0.0001); F5 (OR 1.52, 95 percent CI 1.27–1.83, p- 31 Biopolis Way, does not take into account consumers’ preferences and the Nanos #02-01, value is less than 0.0001); F1 (OR 1.31, 95 percent unique considerations of balancing the trade-offs between Singapore 138669 CI 1.08–1.59, p-value is 0.01); F4 (OR 1.33, 95 the three dimensions of cost, quality and access. In fact, Chen YM, PhD Senior Biostatistician percent CI 1.16–1.54, p-value is less than 0.0001); studies in developing countries have shown that patients’ but not with F6. preferences are influenced by a variety of other factors, Correspondence to: Dr Veena Dhanajay including the service attitude of the providers, and that the Joshi Tel: (65) 6323 8201 Conclusion: This pilot study provides a practical, final choice is determined by a complex interplay of these Fax: (65) 6323 2902 reliable and valid first perception second level (3) Email: veena.d.joshi factors. Studies in the developed world are not dissimilar. @singhealth.com.sg matrix to assess the Singapore healthcare In the United Kingdom (UK), a majority of the public Singapore Med J 2009; 50(10) : 983 believed that they would receive the best possible care that the “state responsibility for healthcare provision” and is most suited to their needs under the UK National Health “satisfaction” as two important dimensions in healthcare Service, irrespective of their ability to pay. However, quality.(9) Dutch researchers have developed an instrument the research done by a network of health professionals to measure different dimensions of public trust in showed that due to cost issues and the breaking of trust healthcare in the Netherlands and had used Cronbach’s with professional groups, this was not necessarily always alpha and exploratory factor analysis to show construct the case.(1) In Australia, a nationwide telephone survey of validity.(10) In Singapore, few studies have been conducted 800 adults carried out in 2007 showed a strong support to determine the factors the general public considers to be for the current healthcare system, but also revealed fairly most important. We aimed to explore the critical factors weak “pro-private” atttitudes and strong “pro-public” that impact public perception of what makes a good attitudes, suggesting an inherent Australian bias towards healthcare system. and describe the development of a publicly-offered healthcare services.(4) The perceptions of questionnaire and analysis to identify the factors associated Canadians about their healthcare system were discussed in with the perception of a good healthcare system. a report to the Health Council of Canada, which reported that the highest priority for Canadians was timely access to METHods care, while quality of care was also a major concern.(5) In The methodology for the survey has been previously another study, Italian citizens questioned the quantity and detailed in Lim and Joshi’s report(11) and will only be quality of the services provided by the Italian healthcare briefly described here. A telephone survey, using a sample system, even though the World Health Report 2000 had frame generated randomly from the 2005/2006 telephone ranked the Italian healthcare system second among 191 directory, was conducted in August 2006. Inclusion countries, with respect to health status, fairness in financial criteria were restricted to respondents who were older than contribution and responsiveness to people’s expectations 21 years of age, who professed to be knowledgeable about of the health system.(6) the household and who could speak English. In Singapore, the government examined the role of The attributes of public perception of the healthcare state healthcare financing and provisions. It was decided system were derived from pre-survey focus group that while the government would continue to subsidise discussions with patients and a survey carried out in healthcare to bring the prices down to an affordable 2003 by Lee et al, on behalf of the Singapore government level, Singaporeans would have to share in the cost of the Feedback Unit.(12) The items were based on healthcare services they consume.(7) The abovementioned studies quality, cost, access and the role of the individual vis-à- suggest that developed countries which had conducted vis society. The initial item pool was further reduced to similar public surveys reported a similar finding of include only items that were clear and not redundant. The multiple factors impacting the perception of healthcare emphasis was on using simple and unambiguous wordings quality. Healthcare quality throughout the world is not and responses. The resulting questionnaire consisted straightforward. It is an “objective” assessment and of 31 questions in total, excluding the demographics. depends on a complex interplay of factors, including Nine items were on the usage of healthcare, 22 items on actual quality of care delivered, timeliness and cost of healthcare perceptions and eight items on demographical services, public expectations and underlying societal characteristics. The responses to each perception item values. Therefore, there is a need to develop an instrument were measured on a five-point Likert scale, ranging from to help providers better understand the multiplicity of “strongly agree” to “strongly disagree”. The responses to perspectives and issues on which healthcare consumers each item on the questionnaire were analysed so that a base their healthcare decisions. It would be expensive and higher item score indicated a more favourable attitude. The impractical to ascertain de novo these myriad elements last section captured the demographics, i.e. information on each time a research is conducted; and we believe factor age, gender, race, education, income, occupation and type analysis is an effective and efficient method which can be of housing. used for identifying underlying dimensions in a group of Correlation was used to determine which items were variables and for developing an instrument that is a brief, associated. One item, “Singapore has a good healthcare practical, reliable and valid measure of public perception system” was not included in the factor analysis, but was of healthcare.(8) only used as a dependent variable in the multinomial A few countries have looked at some of the dimensions regression analysis (Appendix 1). Before the study of healthcare delivery. For example, using data on 14 began, two experts in face validity revised the Healthcare European countries, the Eurobarometer survey highlighted Questionnaire scale, and it was pilot-tested among eight Singapore Med J 2009; 50(10) : 984 Table I.