Healthcare Institutions & Public Opinion: Do Institutions Matter? | Max-Planck-Institut für Sozialrecht und Sozialpolitik - MPISOC

Research Projects

Law and Economics

Healthcare Institutions & Public Opinion: Do Institutions Matter?

Knowing the public opinion on healthcare is essential when assessing healthcare system performance. Public ratings of healthcare services provide policymakers with relevant information on the functioning of healthcare systems and serve as an important indicator of approval of healthcare reforms. Moreover, research suggests that perceptions of healthcare services influence the utilisation of those services and, consequently, health outcomes. Against this background, this project is concerned with the institutional structure of healthcare systems on the one hand, and with what people think of healthcare services in the respective country on the other hand. Specifically, it investigates whether the public’s opinion on healthcare varies systematically across European countries or over time; and whether this variation can be explained by the institutional setting of healthcare in the respective country.

The research questions posed by the project are the following: Can differences in healthcare evaluations between Eastern and Western European countries be explained by differences in the current institutional design of healthcare systems? Do individual attitudes about the unfairness of potential inequalities in healthcare vary systematically with a country’s institutional environment? How do the foreign-born rate health services in the country of residence compared to the country of origin? And do evaluations depend on the healthcare services experienced in these two countries? To what extent were austerity-oriented measures introduced in the Portuguese health sector on the basis of the Memorandum of Understanding after 2011 associated with changes in the public opinion on healthcare in Portugal? And what difficulties in accessing medical services did the public experience in Ireland in times of economic growth and the subsequent economic recession that started in 2008? The results have been published in collaboration with distinguished social scientists specialising in the field of healthcare in various peer-reviewed journals, such as Social Science and Medicine, PloS ONE, Journal of Social Policy, Journal of European Social Policy, Health Policy, and The Economic and Social Review.

Striving for a better understanding of the quality and availability of, and access to, healthcare services, this project consults and combines different research approaches from the fields of social policy, sociology, and social psychology. The results are based on large-scale cross-country comparative survey studies as well as administrative data on healthcare services. In addition, time-comparative case studies are used to examine changes in healthcare institutions and public opinion.

The key research findings are the following:

  • Healthcare Evaluations in Eastern and Western Europe: Studying healthcare evaluations in Eastern and Western Europe, we found support for our hypothesis that differences in the current institutional design of healthcare systems between the two socio-political regions, specifically health institutions’ lower financial resources, higher out-of-pocket payments, and lower supply of primary healthcare services in Eastern compared to Western European countries, can explain East-West differences in healthcare evaluations. We also found that healthcare evaluations follow a coherent cognitive reasoning as they are clearly associated with perceptions of the performance of healthcare systems (i.e. efficiency, equality of treatment, health outcomes), expectations of the government’s role in providing healthcare, and reflections on demographic pressures (i.e. aging populations). Contrary to the general assumption that normative expectations are responsible for explaining East-West differences in healthcare evaluations, we found differences to be largely due to a more negative perception of the performance of healthcare systems within Eastern compared to Western European countries.
  • Perceived Unfairness of Inequalities in Healthcare Worldwide: Studying the relationship between healthcare institutions and the perceived unfairness of inequalities in healthcare revealed the following key findings: Firstly, we found that higher cost barriers correlate with lower levels of perceived unfairness in healthcare inequality, suggesting that those exposed to greater levels of inequality tend to be more accepting of inequality. Secondly, greater public financing of healthcare correlates with higher perceived unfairness, indicating that greater public financing enshrines access to healthcare as a universal right, and hence provides an ideational framing that delegitimises unequal opportunities for purchasing better healthcare. Thirdly, higher unfairness perceptions of lower income and educational groups are more strongly associated with greater public financing than those of their respective comparison groups suggesting that the normative right to healthcare is of particular importance to the disadvantaged.
  • Healthcare Evaluations by the Foreign-Born in Europe: For Ireland, we found that the foreign-born have a more positive opinion than the native-born of the Irish health services. This positive attitude is most pronounced in the first years after their arrival and decreases with time spent in Ireland. Studying the opinions on healthcare by the foreign-born across European countries, empirical results show that the institutional characteristics of healthcare services in the country of residence play a significant role in the evaluations of healthcare of the foreign-born, in particular if healthcare services are compared to those in the country of origin: the better healthcare institutions perform relative to those in the country of origin, the higher the healthcare ratings. The foreign-born tend to evaluate systems more positively if these systems are sufficiently well financed and place less financial burden on the public compared to systems in the country of origin, and if they are primarily funded by compulsory contributory health insurance schemes. Further, when there is a higher density of primary care and inpatient services in the host country than in the country of origin, and when regulations provide access to medical care freely and without restrictions as to provider, approval rates go up. This suggests that knowledge and experience of different healthcare institutions change perspectives and evaluations of healthcare.
  • Healthcare Evaluations and Access to Healthcare during the Economic Crisis: Studying healthcare evaluations in Portugal over time, we found that they improved until 2010 but declined with the implementation of comprehensive austerity measures after 2011. Healthcare evaluations of vulnerable social groups – older and retired individuals, individuals with poor health, low income and educa­tion – dropped particularly strongly. In addition, differences in healthcare evaluations between more and less vulnerable social groups were more pronounced after 2011. Interestingly, healthcare evaluations of the general population and of some of the most vulnerable groups ‘recovered’ in 2015, when most of the austerity-oriented measures had been implemented. When exploring access to healthcare before and during the economic crisis in Ireland, we found that the number of individuals reporting difficulties in accessing healthcare, especially difficulties with the financial costs of covering doctor’s appointments, had started to increase even prior to the economic crisis – specifically for higher income groups. These results correspond with administrative data showing significant increases in hospital charges, outpatient fees, doctor’s fees and dental fees already in the context of strong economic growth. During the economic crisis, as residents experienced increasing levels of co-sharing and the reduction of entitlements to public healthcare supports, cost-barriers continued to grow.
Contact Person(s)

Dr. Simone M. Schneider

Cooperation Partner(s)

Tamara Popic, Ph. D.

European University Institute

Prof. Ellen Immergut

European University Institute

Dr. Camilla Devitt

Trinity College Dublin

Prof. Maria Asensio

ISCTE-Instituto Universitário de Lisboa
Presentations and Contributions
Dr. Simone M. Schneider
Public Opinion on Healthcare: Policy Implications and Research Directions
Dr. Simone M. Schneider
How Unfair are Structural Inequalities in Healthcare? The Role of Institutions
Dr. Simone M. Schneider
The Role of Health Systems in Legitimating Inequalities in Healthcare
Dr. Simone M. Schneider
Is Unequal Healthcare Unfair? The Role of Institutions and Societal Context in Health Justice Evaluations
Dr. Simone M. Schneider
Do Institutions Matter? Studying the Performance of Health Care Systems from a Migrant’s Perspective

Popic, Tamara; Schneider, Simone M.; Asensio, Maria:
Public Opinion on Healthcare in the Context of Economic Crisis: Evidence from Portugal, in: Journal of Social Policy, 48 (2019) 7, p. 741–764.

Schneider, Simone M.; Devitt, Camilla:
Accessing Health Care in Times of Economic Growth and Economic Downturn: Evidence from Ireland, in: Journal of European Social Policy, 28 (2018) 4, p. 357–369.

Schneider, Simone M.; Devitt, Camilla:
How do the Foreign-born Rate Host Country Health Systems? Evidence from Ireland, in: The Economic and Social Review, 49 (2018) 1, p. 45–71.

Schneider, Simone M.; Popic, Tamara:
Cognitive Determinants of Healthcare Evaluations – A Comparison of Eastern and Western European Countries, in: Health Policy, 122 (2018) 3, p. 269–278.

Popic, Tamara; Schneider, Simone M.:
An East-West Comparison of Attitudes towards Healthcare Systems in Europe: Do Institutions Matter?, in: Journal of European Social Policy, 28 (2018) 5, p. 517–534.