1. Background

The objective of this study is to explore and test two opposite theoretical hypotheses gleaned from the recent literature about effects regarding the quality of public healthcare on the willingness to pay more taxes to improve public healthcare. Does a low quality of public healthcare services weaken the willingness to pay more taxes towards improving public healthcare? Alternatively, does a low quality of public healthcare services strengthen such a willingness? Answers to the posited questions are important given the current debate regarding how much people are willing to contribute to improving the quality of public healthcare [1, 2, 3, 4, 5]. The debate is often underlined by a disjuncture between the relatively low tolerance to increased taxation for funding public healthcare, and high expectations regarding the quality of public healthcare. Indeed, research indicates both a strong rejection for increasing taxation to fund public services, and a desire for greater social spending, especially towards the support of public healthcare [6, 7, 8, 9].

One common theoretical perspective put forth in the research literature is that a reduction in the quality of public services will weaken support for such services [10, 11, 12]. This perspective holds that when citizens believe that public healthcare no longer delivers a level of service that either it did in the past, or one that they expect, they will reject public healthcare as a solution, and turn instead to direct out-of-pocket expenditures or private healthcare insurance. This theoretical perspective seems to be driven by rational choice. Citizens weigh the costs and benefits related to public healthcare, and their willingness to support healthcare will be dependent on their perceptions regarding its quality. As such, a higher perceived quality of healthcare will elicit more support. On the contrary, lower perceptions regarding its quality are more likely to undermine peoples’ willingness to pay more taxes to support public healthcare. As emphasized by Andersen [13], although the “the immediate reaction to such problem [low quality of services] may be willingness to spend more, […] in the long run it may result in a decline of confidence and perhaps in a search of private alternatives. Even the most solidaristic person cannot in the long run be assumed to be willing to contribute to a system if it is considered to be inefficient.” Such an attitude inevitably results in a vicious cycle: the public healthcare system is undermined through its delivery of an unsatisfactory quality of services, thus weakening general willingness to pay taxes to support it, and so demands for private healthcare, such as for private health insurance and/or direct out-of-pocket payments, are increased. In turn, lower levels of taxation further constrain an already fiscally-pressured public healthcare system and limit its capacity to increase the quality of services, thus leading to even greater levels of dissatisfaction. Then, this cycle repeats itself. This theoretical perspective allows us to articulate the following testable hypothesis:

H₁ Reduction in the quality of public healthcare services will weaken support for such services.

The opposite hypothesis is that a reduced quality of public services, including healthcare, will boost the willingness to pay more taxes towards improving such services [6, 14, 15]. As such, people may adhere to a strong normative belief that it is the government’s role to take a central place in making sure that healthcare is universally available for all. Past positive experiences with public healthcare provision may further reinforce positive beliefs about the role of government involvement in healthcare delivery. When citizens feel that public healthcare no longer delivers either the levels of services it once did, or the levels that are currently expected, the citizens will support providing more resources to public healthcare in order to improve situation. Consequently, according to this view, a low quality of public healthcare serves as an impetus for shoring up support for public healthcare. This theoretical perspective allows us to articulate the following testable hypothesis:

H₂ Reduction in the quality of public healthcare services will strengthen support for such services.

Although both above-discussed hypotheses appear equally appealing theoretically, the specific question regarding how the quality of public healthcare services affect the willingness to pay more taxes towards improving public healthcare has rarely been the subject of empirical research. The extant literature is comprised primarily of single country studies over a single time period, and which used a single variable to capture quality. What is required however is to test these hypotheses vis-à-vis each other using a diverse sample of countries, and across time, using a rich set of quality indicators.

Against this backdrop, we test the above-discussed hypotheses for 25 post-communist countries over a five-year period using six dimensions of quality. Post-communist countries provide a rich context through which to study the effects of quality on the willingness to pay more to strengthen public healthcare since the expectations regarding healthcare, as well as its quality, have changed dramatically in these countries since the collapse of communism [5, 16]. Before the collapse, these countries used the Semashko-style model which, although inefficient in many aspects, provided universal access to healthcare services that were provided free at the point of use [2]. As a result, these populations inherited expectations of universal healthcare [9]. After the collapse, contact with the West raised expectations regarding the performance of public healthcare [2]. At the same time, post-transitional processes led to the profound underfunding of public healthcare [17]. In turn, such underfunding resulted in greater official out-of-pocket expenditures and unofficial under-the-counter payments, lack of contemporary competencies, technologies, and equipment, and reductions in satisfaction with public healthcare [18, 19]. Because healthcare reforms in post-communist countries will likely require additional funding [20], policy makers and healthcare planners should focus on the factors that influence the willingness to pay more to support public healthcare.

2. Method

3. Results

The results of logistic regression are reported in Tables 4, 5 and 6. Let us commence with Table 4, which reports results for Eurasia. In Armenia, the frequent and unjustified absence of doctors weakens the willingness to pay more for public healthcare, while lack of required medication strengthens the willingness to pay more for public healthcare. Informal payments for services that should be free bolster the willingness to support public healthcare in Azerbaijan. Disrespectful treatment by personnel strengthens willingness to support public healthcare in Kazakhstan. Three dimensions of quality are significant in Kyrgyzstan: long waiting time and unclean facilities are associated with increased support for public healthcare, whereas not having the required medication lessens such support. Long waiting time is also associated with increased support for public healthcare in Tajikistan. In Ukraine, not having the required medication is associated with an increased willingness to support public healthcare. Two quality dimensions, namely, disrespectful treatment by personnel and long waiting time, are associated with a reduced willingness to support public healthcare in Uzbekistan.

Moving to Table 5 with results for Southern Europe, we find that not having the necessary medication strengthens the willingness to support public healthcare in Albania, while having to make informal payments for free services lessens the willingness to support public healthcare. Long waiting time strengthens the willingness to support public healthcare in Bosnia, but weakens it in Bulgaria. In Macedonia, disrespectful treatment by personnel boosts the willingness to support public healthcare, while the lack of necessary drugs lessens the willingness to support public healthcare. Likewise, in Romania, disrespectful treatment by personnel amplifies the willingness to support public healthcare, while unclean facilities lessens the willingness to support public healthcare.

Finally, moving to Table 6 with results for Eastern Europe, we observe that lack of necessary medication boosts the willingness to support public healthcare in the Czech Republic. In Hungary, the frequent and unjustified absence of doctors is found to weaken support for public healthcare, while having to make informal payments strengthens support for public healthcare. In addition, long wait time and informal payments strengthen the willingness to support public healthcare in Latvia and Poland.

4. Discussion

The results presented above lead to broad and rather complex interpretations since most of the significant effects can be attributed, to various degrees, to both tested hypotheses depending on the country under investigation, and the dimension of quality being discussed. In order to reduce this complexity and facilitate a discussion of the findings, the results are summarized in Table 7 and are discussed as follows:

First, country-wise, we found support for Hypothesis 1, which postulates that a lower quality of public healthcare will weaken the willingness to pay more taxes in order to improve it in Armenia, Kyrgyzstan, Uzbekistan, Albania, Bulgaria, Macedonia, Romania, and Hungary. Regarding quality dimensions, Hypothesis 1 is confirmed with respect to frequent and unjustified absence of doctors, absence of required medication, disrespectful treatment by personnel, long waiting time, unclean facilities, and payments required for services that should be free.

Second, with regard to the six quality dimension, we found support for Hypothesis 2, which posits that a low quality of public healthcare will strengthen the willingness to pay more taxes towards its improvement in Armenia, Azerbaijan, Kazakhstan, Kyrgyzstan, Tajikistan, Ukraine, Albania, Bosnia, Macedonia, Romania, Czech Republic, Hungary, Latvia, and Poland. From the perspective of quality dimensions, Hypothesis 1 is confirmed for disrespectful treatment by personnel, absence of required medication, long waiting time, unclean facilities, and payments required for services that should be free.

Third, in some countries both Hypothesis 1 and Hypothesis 2 are true depending on the dimension of quality tested. These countries are Armenia, Kyrgyzstan, Uzbekistan, Albania, Macedonia, Romania, and Hungary. For instance, in Hungary the frequent and unjustified absence of doctors weakens the willingness to pay more to improve public healthcare, while unofficial payment has an opposite effect. For all other countries, only one of the tested hypotheses was found to be true.

Finally, the frequent and unjustified absence of doctors is the only quality dimension that always weakens the willingness to pay more taxes towards its improvement. All other quality dimensions have varying effects depending on the country. For instance, long waiting time weakened the willingness to pay more taxes towards improving public healthcare in Bulgaria and Uzbekistan, but strengthened it in Bosnia, Latvia, Kyrgyzstan, and Tajikistan.

5. Limitations

We need to acknowledge the limitations of this study. To begin, because of the cross-sectional nature of our data, we are not able to make any assertions regarding causality. Second, our data set contains only information about the quality of healthcare from the perspective of patients. Other ways to measure quality include using publicly available data from national quality information systems, measuring the opinions of key informants and healthcare professionals, and soliciting the perceptions of the population at large [29, 30]. Third, the existing literature lacks a theoretical framework regarding the effect of patients’ perspectives on the quality of public healthcare and also lack agreement regarding which quality indicators should be analysed [5, 8]. That being said, examining patients’ perspectives on the quality of healthcare can be seen as empowering patients, politicians, and healthcare planners with the knowledge required to make informed decisions about healthcare reforms and payment strategies. Furthermore, it can also be viewed as cultivating the accountability and transparency of public healthcare [31]. Additionally, because patients are the ones who experience healthcare directly, their views on the quality of the provision of healthcare may bring issues to the surface that have not been revealed through other methods. One such example is the question of how healthcare reforms filter down to the level that is experienced by patients, and to what extent the reforms are acceptable to patients [32, 33, 34].

6. Conclusion and direction of future studies

In this study, we focus on the effect of the quality of public healthcare on the willingness to pay more taxes towards improving healthcare. The current literature is not consistent in explaining the direction of this effect. Two opposite hypotheses are frequently put forth: one that suggests that a lower quality of public healthcare will strengthen the willingness to pay more taxes towards improving it, and the opposite hypothesis by which a lower quality of public healthcare is thought to weaken the willingness to pay more taxes towards improving it.

In light of the above, this is the first study that has tested both hypotheses in the field of healthcare services. As far as we are aware, previous studies were conducted in the areas of education and social welfare, and the studies that have been conducted in the field of healthcare have focused on the analysis of general satisfaction with healthcare and not on its specific dimensions of quality. This is also the first study to focus on a large sample of diverse post-communist countries in Eurasia, and Southern and Eastern Europe over a five-year period.

The main theoretical interpretation of our findings is that a “one size fits all” approach cannot be assumed by healthcare planners and administrators. Rather, there exists considerable variation across countries in terms of the effects of various quality dimensions on the willingness to support public healthcare. This should be expected, inasmuch as we found empirical support for both tested hypotheses. As such, none of the hypotheses gleaned from the literature is a clear “winner.” However, we also found that the situation is less straightforward and more nuanced than the extant literature acknowledges. In fact, our findings suggest that the effect is quality dimension-specific. Thus, within the same country, some dimensions of quality have a positive effect on the willingness to pay more taxes towards improving public healthcare, while other dimensions have an opposite negative effect. Similarly, our findings suggest that the effect of quality is country-specific. Thus, the same quality indicator may have a positive effect on the willingness to pay more taxes towards improving healthcare in some countries, and a negative effect in other countries.

Our main practical interpretation is that for each country under investigation, we provide information regarding which dimension of quality should be addressed to increase support for public healthcare. Let us consider Kyrgyzstan as an illustration of this point. Long waiting times and unclean facilities in Kyrgyzstan strengthen the willingness to pay more taxes to improve public healthcare. In contrast, the absence of medication weakens the willingness to pay more taxes to support public healthcare, while the absence of doctors, disrespectful treatment by healthcare personnel, and informal payments have no significant effect. Consequently, making a clear link between the amounts of extra taxes that will be collected towards increasing the availability of medication will likely increase the willingness to support public healthcare reforms in Kyrgyzstan. In contrast, emphasizing improvements with respect to the absence of doctors, disrespectful treatment by healthcare personnel, and the need for informal payments is unlikely to generate considerable support for healthcare reform. Similar types of interpretations could be made for each country under investigation.

In contrast to other studies that have focused solely on satisfaction with healthcare, our analysis also provides new insights into cross-country differences. For example, patients in Hungary report comparatively lower levels of dissatisfaction with services than do those in other countries surveyed since the Hungarian healthcare system ranks highest in the Euro Health Consumer Index [35]. In addition, the relatively high level of satisfaction expressed in Hungary has also been reported in previous studies [5]. In contrast, our study found that the absence of doctors as well as informal payments were significant precursors to support for public healthcare in that country. Similarly, the previous studies which focused on healthcare satisfaction within the countries of the former Soviet Union reported the highest levels of satisfaction in Azerbaijan and Armenia and the lowest in Moldova [2]. In contrast, our study reveals that respondents stress the negative effects of the absence of doctors and medication in Armenia and informal payments in Azerbaijan. Furthermore, this particular result is consistent with the finding that Azerbaijan is at the lead of countries with respect to the negative impact of informal payments on healthcare satisfaction [12].

As such, the results of our study are also in line with those of previous studies on healthcare satisfaction that have reported only minimal agreement across countries [2, 5, 28]. The inconsistency across countries may be the result of variations in culture, political context, and the influence of the mass-media [8, 36]. Furthermore, inconsistencies could also be rooted in variations in expectations regarding healthcare services, especially when a single relatively generic indicator such as satisfaction with healthcare is employed [37, 38]. Moreover, the existence of this type of discrepancy could also signify weaknesses with respect to the indicators of satisfaction and quality used in this and previous studies [39, 40].

In light of the evidence presented and discussed in this study, future studies should focus on several issues. First, it would be valuable to develop a framework with respect to healthcare quality. Developing such a framework would help identify a set of quality indicators that could be tested for their validity in cross-country and cross-time studies. Second, there is a need to move beyond the analysis of general satisfaction with public healthcare. Instead, efforts should be channelled towards examining the fine details of healthcare performance, including its quality and effectiveness. Finally, future studies should combine different dimensions of data such as the opinions of key informants, the perceptions of patients, healthcare providers, and the general public, as well as the incorporation of government statistics.