QUALITY IN AND EQUALITY OF ACCESS TO HEALTHCARE SERVICES European Commission Directorate-General for Employment, Social Affairs anD Equal Opportunities Manuscript completeD in MarcH 2008 European Commission This study is supported for under the European Community Programme for Employment and Social Solidarity (2007-2013). This programme is managed by the Directorate-General for Employment, social affairs and equal opportunities of the European Commission. It was established to financially support the implementation of the objectives of the European Union in the employment and social affairs area, as set out in the Social Agenda, and thereby contribute to the achievement of the Lisbon Strategy goals in these fields. Neither the European Commission nor any person acting on behalf of the Commission may be held responsible for the use that may be made of the information contained in this publication. Report Authors: ManfreD Huber, AnDerson Stanciole, European Centre for Social Welfare Policy anD ResearcH, Vienna; Jeni Bremner, European HealtH Management Association, Brussels, Kristian WaHlbeck, National ResearcH & Development Centre for Welfare & Health (STAKES), FinlanD. Contributing Authors: ! FINLAND: National ResearcH & Development Centre for Welfare & HealtH (STAKES): Hannamaria Kuusio, Minna-Liisa Luoma, Kristiina ManDerbacka, Lauri Vuorenkoski, Eeva WiDström ! GERMANY: THe Association of Sickness FunDs for Employees (VdAK): Annette Riesberg; TecHnical University of Berlin: Markus Wörz ! GREECE: National ScHool of Public HealtH: Panagiotis Altanis, CHaralambos Economou, Mary Geitona, Susan Gregory, JoHn Kyriopolous, ElizabetH MestHeneos, ElisabetH Petsetaki, JuDy Triantafillou ! THE NETHERLANDS: National Institute of Public HealtH & the Environment (RIVM): Nicoline Tamsma ! POLAND: Centre for Social anD Economic ResearcH (CASE): Stanislawa Golinowska, ADam Kozierkiewicz ! ROMANIA: Institute of Public HealtH: Miaora PreDescu ! SPAIN: AnDalusian ScHool of Public HealtH: Marta Carrillo TiraDo, Inés García SancHez ! UK: University of York, Centre for HealtH Economics, Maria GoDDarD ! Brussels: EuroHealthNet: Claire BlancHarD, Caroline Costongs, Clive NeeDle; European HealtH Management Association: ElisabetH Jelfs, FeDerico Torres. © European Communities, 2008 ReproDuction is autHoriseD proviDeD tHe source is acknowleDgeD. Contents Contents ______________________________________________________ 5 Tables ___________________________________________________________ 10 Figures __________________________________________________________ 11 Foreword_____________________________________________________ 13 Acknowledgments _____________________________________________ 15 Executive summary ____________________________________________ 17 Part 1________________________________________________________ 29 1 Introduction_______________________________________________ 31 1.1 The European policy context __________________________________ 31 1.2 Previous research initiatives __________________________________ 33 1.2.1 Health inequalities across socio-economic groups in Europe _______________ 34 1.2.2 Inequalities in access to and utilisation of healthcare services ______________ 35 1.3 The scope of the study _______________________________________ 36 1.4 The study methodology ______________________________________ 40 1.4.1 The state of the art from the literature and from previous international studies with similar objectives, by drawing on existing research and data______________________ 41 1.4.2 In-DeptH country stuDies ___________________________________________ 41 1.5 Overview of the countries included in this study __________________ 43 1.6 Overview of the report________________________________________ 47 Part 2________________________________________________________ 49 2 Barriers of Access to Health Care ____________________________ 51 2.1 Introduction ________________________________________________ 51 2.1.1 Exploring barriers to access through the lens of vulnerable groups __________ 52 2.2 Coverage and cost-sharing barriers: ____________________________ 58 2.2.1 Population coverage for health care under public programmes _____________ 58 2.2.2 The scope of the health basket ______________________________________ 64 2.2.3 Cost-sHaring requirements as a barrier to access ________________________ 74 2.3 Conclusions and Recommendations____________________________ 91 2.3.1 Coverage as barrier to access_______________________________________ 91 2.3.2 Health baskets as barrier to access___________________________________ 93 2.3.3 Cost sHaring ____________________________________________________ 94 3 Broader System Barriers ____________________________________ 96 3.1 Introduction ________________________________________________ 96 3.2 Geographical barriers of access to health services________________ 97 3.2.1 Transport _______________________________________________________ 97 3.2.2 Concerns about regional variations in access ___________________________ 98 3.2.3 The growing divide between rural and urban areas______________________ 102 3.2.4 Policies to reduce geograpHical variations in access to services ___________ 104 3.3 Organisational barriers ______________________________________ 111 3.3.1 Organisational barriers limiting access to health care ____________________ 113 3.3.2 Policies to improve access to primary care: out-of-hour services and reduction of waiting times__________________________________________________________ 115 3.3.3 Persistent problems with waiting lists ________________________________ 116 3.3.4 Policies to improve access by reducing waiting times ____________________ 119 3.4 Supply-side responsiveness _________________________________ 122 3.4.1 Evidence on the influence of supply-side responsiveness ________________ 123 3.4.2 Policies to improve supply-side responsiveness ________________________ 131 3.4.3 Community health initiatives to promote access ________________________ 133 3.5 Health literacy, voice and health beliefs ________________________ 142 3.5.1 What do we know about deficiencies in Health literacy? __________________ 145 3.5.2 Evidence from country stuDies of access problems Due to low health literacy _ 147 3.5.3 Policies to improve health literacy anD to empower people at risk of social exclusion ____________________________________________________________ 150 3.6 Conclusions and Recommendations___________________________ 152 3.6.1 Organisational barriers to access ___________________________________ 152 3.6.2 Supply-side responsiveness _______________________________________ 153 3.6.3 GeograpHical barriers anD regional variations__________________________ 154 3.6.4 Measures to improve HealtH literacy for reDucing barriers of access_________ 155 Part 3_______________________________________________________ 157 4 Migrants, asylum seekers and illegal immigrants_______________ 159 4.1 Introduction _______________________________________________ 159 4.1.1 How do countries differ in their role of host country?_____________________ 160 4.1.2 Which definitions and concepts for “migrants” Does HealthQUEST follow? ___ 162 4.2 Migrants and ethnic minorities________________________________ 164 4.2.1 The socio-economic situation of migrants and ethnic minorities ____________ 165 4.2.2 Health and illness patterns ________________________________________ 166 4.2.3 Coverage anD health basket _______________________________________ 169 4.2.4 Healthcare services utilisation ______________________________________ 171 4.2.5 Barriers of access to HealtHcare ____________________________________ 173 4.2.6 Policy and practice initiatives: ______________________________________ 178 4.3 Asylum seekers and refugees ________________________________ 182 4.3.1 Main countries of origin ___________________________________________ 183 4.3.2 Health and illness patterns ________________________________________ 185 4.3.3 Coverage anD health basket _______________________________________ 186 4.3.4 Healthcare services utilisation ______________________________________ 190 4.3.5 Barriers in access to Health care ____________________________________ 191 4.3.6 Policy initiatives to improve access to health care for asylum seekers _______ 192 4.4 Illegal immigrants: ‘sans papiers’ or ‘undocumented migrants’_____ 196 4.4.1 Health and illness patterns ________________________________________ 197 4.4.2 Coverage anD health basket _______________________________________ 198 4.4.3 Other barriers __________________________________________________ 199 4.4.4 The role of NGOs in supporting illegal immigrants ______________________ 200 4.5 The situation of older migrants _______________________________ 202 4.5.1 Specific concerns about older migrant women _________________________ 206 4.6 Conclusions _______________________________________________ 208 4.6.1 Migrants are relatively more affected by certain health problems ___________ 208 4.6.2 A higher risk of poverty and social exclusion contributes to worsen health status 209 4.6.3 Multiple risks increase exposure to multiple barriers _____________________ 209 4.6.4 The protection provideD by most countries is not sufficient ________________ 210 4.6.5 Access barriers limit the use of services ______________________________ 210 4.6.6 Asylum seekers face additional barriers in accessing healthcare ___________ 211 4.6.7 Illegal migrants likewise face additional barriers in accessing HealtHcare _____ 212 4.6.8 .The difficulties in obtaining Documents place serious restrictions on access to Healthcare____________________________________________________________