Search

Objective This paper examines how negative experiences with the health-care system create a lack of confidence in receiving medical care in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. Methods The empirical analysis is based on data from the Commonwealth Fund International Health Policy Survey 2007, with nationally representative samples of adults aged 18 and over. For the analysis of the experience of cost barriers and confidence in receiving medical care, we conducted pairwise comparisons of group percentages as well as country-wise multivariate logistic regression models. Results Individuals who have experienced cost barriers show a significantly lower level of confidence in receiving safe and quality medical care than those who have not. This effect is most pronounced in the United States, where people who have foregone necessary treatment because of costs are four times as likely to lack confidence as individuals without the experience of cost barriers (adjusted odds ratio 4.00). In New Zealand, Germany, and Canada, individuals with the experience of cost barriers are twice as likely to report low confidence compared with those without this experience (adjusted odds ratios of 1.95, 2.19 and 2.24, respectively). In the Netherlands and UK, cost barriers are only a marginal phenomenon. Conclusions The fact that the experience of financial barriers considerably lowers confidence indicates that financial incentives, such as private co-payments, have a negative effect on overall public support and therefore on the legitimacy of health-care systems. [ABSTRACT FROM AUTHOR]

Theories of democratic government traditionally have relied on a model of organization in which officials act impartially, accept clear lines of accountability and supervision, and define their day-to-day activities through rules, procedures, and confined discretion. In the past 10 years, however, a serious challenge to this ideal has been mounted by critics and reformers who favor market, network, or "mixed-economy" models. We assess the extent to which these new models have influenced the work orientations of frontline staff using three alternative service types—corporate, market, and network—to that proposed by the traditional, procedural model of public bureaucracy. Using surveys of frontline officials in four countries where the revolution in ideas has been accompanied by a revolution in methods for organizing government services, we measure the degree to which the new models are operating as service-delivery norms. A new corporate-market hybrid (called "enterprise governance") and a new network type have become significant models for the organization of frontline work in public programs. [ABSTRACT FROM AUTHOR]