PATIENTS' SATISFACTION WITH THE HEALTH CARE SYSTEM IN THE AGE OF GLOBALIZATION: THE CASE OF ROMANIA.

• Author: Burcea, Marin

1. Introduction

   Since the late 1980s, the world has entered into a new phase of its evolution as several influential forces, such as globalization, technological innovations or demographic changes have brought many transformations (e.g. economic, political, and social) all over the world. The fall of the Berlin Wall led to the establishment of a new world system, dominated by the capitalist economy. However, there is still a dispute between the proponents of free market and the advocates of governmental interventions, especially due to the economic performance achieved by middle-income countries such as China or Turkey (World Bank, 2013).

   In the post-modern society, globalization represents a multi-faceted phenomenon and its impact on health care has been fast-tracked in a wired world. On the one hand, it constitutes an important topic within the debates relating to health care due to the fact that some of its effects (for example the disparities between countries in health infrastructure, the free movement of doctors, the spread of diseases, the medical tourism, etc.) raised difficult problems for governments around the world (Labonte and Schrecker, 2007; Huynen et al., 2005). 'An increasing tension between the new rules, actors and markets that characterize the modern phase of globalization and the ability of countries to protect and promote health' (Woodward et al., 2001, p. 875) has emerged in the last decade. On the other hand, globalization has increased the access to health care services, drugs, medical knowledge, and training that can lead to the prevention, treatment or cure of diseases in various regions of the world, and urges the adoption of health standards and norms through global agreements (Beaglehole and Yach, 2003). In this respect, there is a need for reaching the goal of universal health coverage (WHO, 2013).

   As globalization impacts directly or indirectly the human society, it can bring both health benefits and threats (Saker et al., 2004). That is why different stakeholders, such as governments, health policy-makers, public health practitioners, health care researchers, public organizations, corporations, non-government organizations and patients associations, are highly involved in finding solutions at both the national and international level. In this respect, the transmission of health related knowledge has become very important in the age of globalization. In essence, 'the health and life-expectancy of the vast majority of mankind, whether they live in rich countries or poor countries, depends on ideas, techniques, and therapies developed elsewhere, so that is the spread of knowledge that is the fundamental determinant of population health' (Deaton, 2004, pp. 2-3).

   Health care has increasingly become a complex issue of the political, social and economic environment in a globalized world. Today, there are much more pressures (for e.g. financial, demographic, and technological) on the health care systems to deliver quality services to patients than in the past. Consequently, the protection of patients' rights has evolved into a key aspect of the new global health agenda (Ahoobim et al., 2012). During the time, these rights have expanded 'in parallel with the recognition of the role of citizens in the society' (Mira et. al., 2012, p. 365). Today, they cannot be understood solely within the national boundaries of a state (European Parliament, 2011). Significant efforts have been made by national public health organizations, health promotion agencies, health service providers, scientific research institutions and consumers associations in order to promote and support the protection of patients' rights worldwide. In the last two decades, researchers have analyzed the patients' rights and their protection in direct and/or indirect connection with quality in health care (Groene et al., 2013; Luxford, 2012) and quality improvement (Goeschel et al., 2012; Green et al., 2012; Ovretveit and Klazinga, 2012; Parand et al., 2012), patients' experiences (Zuidgeest et al., 2012; Rahmqvist and Bara, 2010) and complaints (Schniteer et al., 2012), trust in the health services provider-patient relationship (Brennan et al., 2013), responsiveness of health systems (Coulter and Jenkinson, 2005), and patients' satisfaction (Rivers and Glover, 2008; Jenkinson et al., 2002).

   Patients' satisfaction with health care systems has been a widely debated topic for both practitioners and researchers, especially starting from the assertion that satisfaction and quality of care are two interrelated concepts (Campen et al., 1995; Donabedian, 1980). Patients' satisfaction is considered as one of the most important and desired outcomes of the health care services (Naidu, 2009). Another concept that appears in the debates about the quality of health care services is corruption. Discussions within the World Health Organization (WHO) lead to the conclusion that it is about a specific taxonomy of the payment received which is illegal. Killingworth (2002) refers to the corruption in the health care system as being unofficial payment and/or informal, as opposed to the official payment, payment that 'does not have an approval mark' in compliance with the official regulations, being created for authorized reasons to combine intrinsic motivation ('health', 'burden of illness', 'scope of the health care system', etc.) or extrinsic motivation. Sometimes, the term of unofficial payment may include the informal payment and what is considered to be the opposite of official payment, as it has been specified before.

   In our country, only a quarter of Romanians evaluate the healthcare system positively (Cotiu et al., 2014), while most Romanians consider that hospital services quality is low (Jankauskiene, 2011). The main complaints of the patients are related to accommodation and lack of medicines in hospitals, and the long time waiting in the ambulatory system (Francu and Francu, 2012).

   On the other hand, The European Commission Report on Corruption in the EU Countries (European Commission, 2014) reveals that more than 84% of the Romanians think that corruption is widespread in their country. According to the Global Corruption Barometer (Transparency International, 2013), 17% of Romanians pay a bribe to public services. Corruption is widespread in the Romanian public health system, especially due to the low salaries of doctors and medical staff. A study conducted in 2009 (Farcasanu, 2010) shows that more than 20% of Romanians consider that corruption is the main problem of the Romanian health system.

   The main types of healthcare corruption are bribery, collusion in procurement and clientelism, favoritism and nepotism (European Commission, 2013). 28% of the Romanians recognize that they have to make an additional payment or give a gift or hospital donation (European Commission, 2014). Informal payments in Romania represent around 6.3% of total health expenditure (Pavlova et al., 2012). According to the ASSPRO CEE 2007 Project:

   --More than 25% of Romanians paid informally for physician visits;

   --Nearly 50% of all patients in Romania paid informally for hospitalizations; and

   --72% of Romanian actual and potential health care users had a negative attitude towards informal cash payments for health care.

   Arising from the above discussion emerge two interconnected questions regarding patients' satisfaction and corruption in the Romanian health care system. These are:

   --Which is the level of patients' satisfaction with the health care system in Romania?

   --Which is the level of corruption in the Romanian health care system?

   The aims of our paper are to present the theoretical approach about the concept of patients' satisfaction and to analyze the results of a research regarding the satisfaction of the Romanian patients towards the health care system and health care services.

   The following section of our paper analyzes the concept of patients' satisfaction while the last section deals in details with the research methodology and actual findings of the research.

2. Conceptual framework

   As a multidimensional concept, the patients' satisfaction has been extensively studied in the literature (Gill and White, 2009). Firstly, it is related to the patients' rights. Secondly, the concept is predicted by several factors such as service quality, competence of the medical staff, and confidence or professional credibility.

   Patients' rights are placed within the broader framework of human rights (Active Citizenship Network, 2002) and represent only a part of consumer rights (Figure 1). The emergence of patients' rights derives directly from the evolution of human rights. In fact, there is a clear correspondence between human rights, consumer issues and patients' rights (Table 1). As 'the patient's perspective is becoming more and more integrated in the process of improving health-care systems' (Rahmqvist and Bara, 2010, p. 86), patients' rights are now at the forefront of the debates in the European Union.

   The respect of patients' rights constitutes a prerequisite for achieving patients' satisfaction. But, patients' satisfaction is highly connected with health care quality. As any type of quality in the domain of services, health care quality is difficult to define and measure due to its specific features (e.g., intangibility, heterogeneity). However, medical care quality refers to the production of improved health and population satisfaction (Palmer et al., 1991) or to the capacity of the elements of that care to accomplish both medical and nonmedical objectives (Steffen, 1988). Therefore, health care quality is positively correlated with patients' satisfaction.

   Without being a clearly defined concept (Bleich et al., 2009...