Chapter 8. Being responsive to citizens’ expectations: The role of health services in responsiveness and satisfaction

8.1 Introduction The world health report 2000 on the performance of health systems posited responsiveness to citizens’ expectations as a central and particular goal. It pushed forward a debate that frames responsiveness as a valued and desired outcome of health system interventions regardless of the extent to which those interventions lead to health improvement (1). As noted in chapter 3, health services reforms place ever increasing emphasis on meeting citizens’ expectations, improving responsiveness to patients and increasing both population and patient satisfaction. In recent years, many countries have introduced reforms to enhance transparency, patients’ rights and entitlements, choice of provider and access to services – all core elements of responsiveness. These strategic attempts to boost efficiency (by introducing market forces), improve access and increase the quality of the services are also intended to improve a system’s responsiveness to the justified expectations of the population, albeit some of the reforms respond primarily to the articulate and advantaged. The European Observatory’s book on social health insurance (SHI) systems in western Europe (2) marshals evidence around this issue. Saltman et al. (2) show that, on average, these systems are associated with higher levels of responsiveness. However, they hypothesize that this correlation is not directly attributable to the funding mechanism but rather is due to other factors that are more pronounced in SHI countries. For example, the benefit baskets of covered services (i.e. the entitlements of the insured) have been defined more clearly. In addition, on average SHI countries spend a higher percentage of their gross domestic product on health care than tax-funded systems. Such extra costs or trade-of