WSF TWS: Health Politics, Health Policy, Long-Term Care and Inequalities

WSF Thematic Workshop on “Health Politics, Health Policy, Long-Term Care and Inequalities” took place in Mannheim, Germany, from 4-6 October 2016

Click here to access the full programme: WSF Thematic Workshop Health Oct 2016 [pdf]

Summary by Claus Wendt, Nadine Reibling, HiNEWS | University of Siegen | reibling (at)

Claus Wendt, Workshop Organizer

The Thematic Workshop “Health Politics, Health Policy, Long-Term Care and Inequalities” at the Mannheim Center for European Social Research, Germany, brought together expertise on healthcare and long-term care from the Welfare State Future teams EXCELC, HEALTHDOX, and HiNEWS. The projects have common interests and facilitate cutting-edge research in areas such as comparative healthcare systems and reforms, carework and performance, and methodological challenges and pathways linking healthcare systems to population health and public attitudes. New typologies of healthcare and long-term care systems has been presented as tools for better capturing these systems’ effects. The power of ideas for stimulating health reform and institutional change has been analyzed on the basis of pro-market reforms in Central Eastern Europe. The question of values and guiding ideas also plays a role in the study of health and human rights in the context of the Greek refugee crisis. Further papers have focused on people’s perceptions of different institutional settings in healthcare and studied the institutional context in which people with limited health conditions evaluate their healthcare system more critical. By comparing Eastern and Western Europe, it has also been shown that the evaluation of healthcare systems is strongly related to a positive perception of the systems’ performance. Health reforms such as the Swedish waiting time guarantee and the experience of shorter waiting times seem to lead to a substantial increase in hospital service satisfaction. More generally, the perception of healthcare systems is related to the experience of access to healthcare services, and it has been shown that this experience is related to the employment status and a person’s history of unemployment in different welfare state regimes. A comparison of Belgium, the Netherlands, Norway, and Denmark demonstrates a reciprocal effect in this context. Both unemployment and disability likelihood is remarkably similar for people with ill health across the four countries. In a methodological paper, finally, it has been tested whether the Best-Worst Scaling (BWS) can be used as a valid instrument for assessing decision-making processes in health and long-term care. Overall, it has been a stimulating event carried by the spirit of an interdisciplinary team of young researchers and possibly also by the visit to the Max Weber House in Heidelberg. Weber’s focus on ideas, interests, and institutions plays a role in almost all of the work presented at the workshop.

Nadine Reibling, Mareike Ariaans, Claus Wendt, HiNEWS | University of Siegen | reibling (at)

How many Worlds of Healthcare? A New Healthcare System Classification of 30 OECD Countries

Nadine Reibling

In this paper, we build on the variety of healthcare system typologies that contribute to our understanding of the similarities and differences how healthcare is organized in advanced, industrialized countries. The majority of existing classifications are based on three key dimensions: funding, provision, and regulation. Recent debates have asked to what extent these typologies can help us explain the cross-national variation in population health and health inequalities. We argue that in order to make healthcare system classifications fruitful for this question, it is necessary to go beyond structural indicators of funding and provision. In particular, we argue that it is important to consider the relative importance of different healthcare sectors/functions (provision, primary care, curative, etc.) as well as the quality of the care provided as additional dimensions. Moreover, recent reforms have substantially changed healthcare systems in the OECD and require an update of existing classifications. Based on quantitative and qualitative indicators from various international comparative data sources and an expert survey, we develop a healthcare system typology including 30 OECD countries. Using cluster and latent-class analysis, we present distinct types of healthcare provision and the relative fit of individual countries to these types. The results is compared to earlier classifications and based on this comparison, we assess convergence/divergence trends across OECD healthcare systems.

Mareike Ariaans, HiNEWS, Thomas Bahle | Mannheim Centre for European Social Research (MZES) | Mareike.Ariaans (at)

Mapping Long-Term Care Systems

Mareike Ariaans

In the context of a new research project on the coordination of elderly care services between healthcare and long-term care services, this work aims to compare the institutional characteristics of European healthcare and long-term care systems. Therefore, we aim to provide a new long-term care typology which is comparable to existing healthcare typologies (especially the one presented by Reibling, Wendt, Ariaans at the workshop). A new long-term care typology is needed, because most empirical typologies include long-term care as part of social services typologies or focus on specific aspects of long-term care systems – for example migration, family caregiving or cash-for-care schemes. The few typologies aiming at capturing the whole institutional structures of long-term care systems do not use similar dimensions and indicators as healthcare typologies. Thus, long-term care typologies (as well as their clusters and countries) cannot be compared to existing healthcare typologies and a new long-term care typology is needed.

Tamara Popić, HEALTHDOX | University of Lisbon | tamara.popic (at)

Ideas, Institutions and Politics in Market-Oriented Healthcare Reforms in Central Eastern Europe

Tamara Popic

In my paper, I dealt with differences in success of governments in three Central Eastern European (CEE) countries to introduce market-oriented healthcare reforms. These reforms envisaged substantial changes, including privatization and commercialization of public hospitals, introduction of competition in health insurance sector and privatization of healthcare costs through introduction of user fees for a large range of medical services. Despite significant reform efforts in three CEE countries – Czech Republic, Slovakia and Hungary – to introduce these market reforms, the actual outcomes varied. While Slovakia successfully introduced the whole set of reforms, Czech Republic managed to pass just one part of its reform plan, and in Hungary the whole reform utterly failed. In the paper, I explain this varying success of government efforts by three different elements of policy change – ideas, institutions and politics. The paper shows that while strikingly similar ideas about the role of markets in healthcare were main drivers of the healthcare reforms in all three countries, the success of these ideas in bringing about policy change crucially depended on institutional veto points and country-specific political arrangements. The paper contributes to the existing literature on policy change by identifying conditions under which governments are able to implement their reform plans. It also makes empirical contribution to a relatively underexplored topic of healthcare policy development in the post-communist countries of Central Eastern Europe.

Courtney McNamara, HiNEWS | Norwegian University of Science and Technology | courtney.mcnamara (at)

Health, Human Rights and the Greek Refugee Crisis

Courtney McNamara

This work is situated in the context of the Greek Refugee Crisis and forms part of the research project ‘Refugee health in Greece’ (REHEAL). As part of the REHEAL project, 367 refugees were surveyed in Greece, across 6 refugee camps. Data was collected on a range of demographic, socioeconomic and health conditions, along with respondent’s migration experience. The aim of this work is to contextualize this data with reference to human rights frameworks. At the national, regional and international levels there are a range of hard and soft laws, principals and rights with relevance to refugees. The next step of this work is to map this human rights territory and examine how it can be related back to the data collected by the REHEAL project.

Oliver Nahkur, Mare Ainsaar, HEALTHDOX | Tartu University | oliver.nahkur (at)

Why People with Limited Health Conditions Evaluate Health Systems more Critically – Comparison of 15 European Countries

Oliver Nahkur

In our research we compared people with better and worse health conditions in 15 European countries regarding their satisfaction with healthcare system and tried to find explanations to satisfaction differences. Using data from European Social Survey 2014, we found that people with worse health conditions tend to be less satisfied with their countries’ healthcare system. In Austria, Sweden and Slovenia, people with worse health conditions tend to be less satisfied with their countries’ healthcare system because they are generally more critical as they are less satisfied with their government overall. In Estonia and Belgium the people with worse health condition is less satisfied with the healthcare system mainly because they have less economic resources. Experience with the access to healthcare service were not significant mediator between satisfaction with the healthcare system and health condition.

Simone Schneider, HEALTHDOX | Trinity College Dublin | sschneid (at)

Tamara Popic, HEALTHDOX | University of Lisbon |

How “Reasonable” is the Public’s Opinion on Health Systems? – An Analysis of the Psychological Components of Health System Evaluations across Eastern and Western Europe

Simone Schneider

In our study “How ‘reasonable’ is the Public’s Opinion on Health Systems? – An Analysis of the Psychological Components of Health System Evaluations across Eastern and Western Europe”, we explored the public’s opinion on health systems across European countries. Based on cross-comparative survey data, we tried to find answers to two principle research questions: First, is the public’s opinion on health care systems based on a coherent, cognitive reasoning (e.g. performance perceptions, normative expectations, consideration of external forces)? Second, can differences in the public’s evaluation of health services between Eastern and Western European countries be attributed to differences in the expectations on health systems (legacy hypothesis) or perceptions of the health system’s performance (performance hypothesis). The empirical analysis was based on the fourth round of the European Social Survey using multilevel modelling and multilevel mediation analysis. We found health system evaluations to depend on various factors, most strongly on the perceived efficiency of health systems. Further, we found perceptions of the efficiency and of the equality in health treatment to fully explain, why Eastern Europeans are more critical towards the health system than Western Europeans. In sum, our findings support the assumption that health system evaluations are reasonable and individuals base their evaluations on their perception of various performance components, their expectations, and also take external forces (e.g. demographic change) into consideration. Our results further underline the need for more research on the contextual differences in the public’s opinion towards welfare systems, and health care in particular.

Björn Rönnerstrand, HEALTHDOX | University of Gothenburg | bjorn.ronnerstrand (at)

Standing in Line when Queues are on Decline: Policy Proximity and Evaluations of Healthcare Services fFllowing the Swedish Waiting Time Guarantee

Björn Rönnerstrand

Waiting time is the Achilles heel of the Swedish healthcare system, and most policies enacted to improve access have failed. Yet while the 2005 waiting time guarantee did not reduce waiting times in most parts of Sweden, it resulted in drastically lower waiting times in Västra Götaland County. In this study hospital service satisfaction in Västra Götaland is measured before and after the implementation of the reform. This design provides a unique opportunity to address questions of significant theoretical relevance in the literature about public responsiveness and policy feedback effects. The objectives of this paper are to investigate the link between proximity and visibility and hospital service satisfaction, to investigate if the decrease in waiting times resulted in increased hospital service satisfaction and to investigate if the effect of the decrease in patients’ waiting times on public hospital service satisfaction was moderated by policy proximity and visibility. Data from a SOM survey in West Sweden is utilized, measuring both hospital service satisfaction and indicators of policy proximity and visibility in 2004–2009. To disentangle the role of policy proximity, two indicators are used — user status and subjective health status. Furthermore, policy visibility is measured by an individual’s level of political interest. The results of the analysis show that policy proximity and visibility was closely linked to hospital service satisfaction and that the decrease in waiting times was followed by a substantial increase in hospital service satisfaction. However, the increase in service satisfaction was not more pronounced among groups with higher proximity and visibility. On the contrary, results indicate that the increase in hospital service satisfaction was stronger among those already in good health.

Ave Roots, HEALTHDOX | Tartu Unviversity | ave.roots (at)

Access to Medical Care Depending on the Employment Status and History of Unemployment in different welfare regimes and Healthcare Systems

Ave Roots

Health inequalities between employed and unemployed have been widely studied and found that unemployed have systematically lower health status. Inequalities in access to health care depending on the employment status have not been studied that much. Different welfare regimes and health care systems both play their role as mediators between employment status and access to health care. Using the gradual approach of employment status between employed and unemployed, the group of employed was divided into those with the experience of unemployment and those without it. In 2014 European Social had the special health inequalities block and it has been utilised in current study. European Social Survey data shows that employed with the experience of unemployment are in several countries more likely not to get medical consultation or treatment in case of need compared to the employed who have never been unemployed, whereas the last group often does not differ from unemployed. The worse access to medical care of the employed with unemployment history is associated with worse working conditions compared to those who have not been unemployed in Estonia, Great Britain, Ireland, Poland and Portugal. These countries have strict access restrictions on the primary level of health care and the Anglo-Saxon and the Eastern-European countries also have more liberal labour markets that amplify the differences between mentioned groups on the labour market.

Veerle Buffel | Ghent University | veerle.buffel (at)

Kristian Heggebø | NOVA Norwegian Social Research

Unemployment and Disability Likelihood for People with Ill Health: Does the Institutional Setting Matter? Evidence from Belgium, the Netherlands, Norway, and Denmark

Veerle Buffel

High employment rates among ‘vulnerable groups’ is an important policy goal, and it is therefore vital to examine whether certain institutional settings are able to enhance labor market participation for people with ill health. Belgium, the Netherlands, Norway and Denmark share a large number of characteristics, but there is also important differences in institutional settings of (potential) importance for labor market outcomes. The four countries are analyzed using OLS regressions and propensity score kernel matching of EU-SILC panel data (2010—2013). Both unemployment and disability likelihood is remarkably similar for people with ill health across the four countries, despite considerable institutional differences. The only major exception is Denmark, where unemployment probability is comparatively high for people who deteriorate in health. The main finding, however, is cross-national similarity, for which there are three major explanations. First, different institutional combinations could lead towards the same results for the target group. Second, most policy instruments are located on the supply side, and demand side reasons for the observed ‘employment penalty’ (e.g. employer skepticism/ discrimination) are often neglected. Third, it is too demanding to hold (full time) employment for a sizeable proportion of those who have poor health status.

Laurie Batchelder, Julien Forder, Kamilla Razik, EXCELC | University of Kent at Canterbury | L.Batchelder (at)

Juliette Malley, EXCELC | London School of Economics

How do People Make Decisions about ‘Best’ and ‘Worst’ Quality of Life States? A Qualitative Exploration of Best-worst Scaling Responses to the ASCOT Measure of Care-related Quality of Life

Laurie Batchelder

Stated preference techniques are often used to elicit preferences for different quality of life states described by multi-attribute measures. One method for eliciting preferences is Best-Worst Scaling (BWS), a choice-based technique derived from random utility theory. However, the BWS task has few applications, and its acceptability, feasibility and validity – in terms of the extent to which decisions about best and worst states abide by the assumptions of utility theory – are not well understood. The aim of this study was to provide a better understanding of the BWS task as a method used to elicit preferences for the ASCOT service user (ASCOT-S) and carer (ASCOT-C) measures. Twenty adult participants were presented with either the ASCOT-S (8 participants) or the ASCOT-C (12 participants) and were asked to ‘think-aloud’ while completing the BWS task to assess their decision-making process. After they completed the task, participants were then interviewed to provide a further understanding of their decision-making processes. In terms of feasibility and acceptability, results showed that participants were able to put themselves into the hypothetical quality of life states and complete the tasks. However, some people found the task difficult or were uncertain of whether they were doing the task correctly, and many participants found the task repetitive. In terms of validity, some participants used heuristics to aid their decision-making, for example by grouping attributes together according to importance or whether the wording was positive or negative. However, this simplification strategy appeared alongside trading between aspects. Some people may have been constructing their preferences as the task progressed, and respondents tended to be fairly inconsistent in their responses to the repeated choice task. Consistency, however, was fairly good when their first and second responses were considered together, suggesting that some inconsistency may simply be due to random error. The use of the BWS technique is still in its infancy in the field of health and long-term care. Our findings suggest that the BWS task is acceptable and feasible but the accessibility of the task needs careful consideration to ensure participants are able to engage with it fully. The results raise some questions about the validity of responses for all participants, but it is our view that on the whole the data are valid.