Most people unhappy with their health system | News

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December 13, 2023 — The first step in improving a health system is to understand how it is performing. Governments often focus evaluations on metrics like number of providers or health facilities, but this approach is limited, according to a team of health policy researchers from Harvard T.H. Chan School of Public Health. Drawing on data from a 15-country survey, they aim to fill in what they see as a crucial gap in many health system assessments—the opinions of health care consumers.

In a series of six papers published online in Lancet Global Health on December 12, the researchers compared various aspects of health system performance globally, including people’s confidence in their health system and views on the quality of care they’ve received, inequities in coverage and quality, and links between health system quality and COVID-19 vaccination rates.

The studies used data captured in 2022 and 2023 from more than 25,000 adults across 15 countries: Argentina, Colombia, Ethiopia, Greece, India, Italy, Kenya, Laos, Mexico, Peru, South Africa, South Korea, United Kingdom, United States, and Uruguay. Participants were contacted through the People’s Voice Survey, a new instrument designed by the Quality Evidence for Health System Transformation (QuEST) Network, a multicountry research consortium based at Harvard Chan School.

Through the survey data, the researchers were able to get a better picture of how health systems actually function, said Todd Lewis, research associate in the Department of Global Health and Population, a co-author on several of the papers, and People’s Voice Survey lead researcher. “While many surveys focus on the experience of recent patients, our analyses examine the views of the entire population. This provides a much more comprehensive snapshot of population sentiment about the health system and can be powerful information for policymakers.”

The overarching message coming out of the survey is that people across the world are not confident that their health systems can meet their needs. Only one-quarter of respondents said their system worked well, and fewer than half were confident that they could get and afford good quality care if they were to become sick—even in countries with universal insurance systems.

“The level of unhappiness in the health systems of high-income countries was surprising,” said Margaret Kruk, professor of health systems and director of the QuEST Network. For example, 70% of Ethiopians think their health system has been improving over the past two years while just 6% of Britons and 15% of Americans do. Kruk, also a co-author on multiple papers and principal investigator of the People’s Voice Survey, thinks this is in part due to dissatisfaction around governments’ responses to COVID, in addition to other factors such as staffing problems in the health workforce.

Other key findings from the series:

  • Women and people with post-secondary education, and, in some countries, young people, were more pessimistic about their health systems than respondents with lower education levels, men, and people older than 30 years.
  • People who recently received high quality care and reported feeling confident in their health system were more likely to have received a COVID-19 vaccination, whereas people who had unmet health needs or experienced discrimination from a provider were less likely.
  • In countries with a public primary care system, only four in ten people use public primary care as their usual provider. Others rely on private providers and secondary care facilities such as hospitals.
  • The availability of public health insurance in Africa and Asia isn’t necessarily leading to more people receiving important preventive services. For example, people with public insurance aren’t much more likely to receive blood pressure checks than people without insurance and are less likely to receive them than people with private insurance.
  • In Latin America where health insurance coverage is high, inequities in care persist. While people reported high access to care, only one in three respondents had a high-quality source of care. Only one quarter of respondents said that their mental health needs were met. 

Kruk said that the pessimism expressed across countries by people with higher incomes and more education, and by young people, “bodes poorly for future support for publicly financed insurance, including efforts for universal health coverage, as these groups are essential contributors to any such scheme.” She and her colleagues suggest that governments will need to gain trust from their populations before moving ahead with health system reforms.

Other Harvard Chan School authors include: Catherine Arsenault, Rodrigo Bazua-Lobato, Kevin Croke, Rashmi Dayalu, Neena Kapoor, Gillian SteelFisher, and Katherine Wright.

Amy Roeder

Photo: iStock / XiXinXing


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