Inequalities in access to healthcare. A study of national policies 2018

Abstract

This report explores inequalities in access to healthcare in 35 European countries. It shows that important inequalities persist, both between and within countries. Large shares of the EU population, in particular vulnerable groups, face multiple hurdles and do not obtain the care they need.

Full text

Rita Baeten, Slavina Spasova, Bart Vanhercke
and Stéphanie Coster
November 2018
Inequalities in access
to healthcare
A study of national policies
2018

EUROPEAN COMMISSION
Directorate-General for Employment, Social Affairs and Inclusion
Directorate C — Social Affairs
Unit C.2 — Modernisation of social protection systems
Contact: Giulia Pagliani
E-mail: Giulia.PAGLIANI@ec.europa.eu
European Commission
B-1049 Brussels

EUROPEAN COMMISSION
Directorate-General for Employment, Social Affairs and Inclusion
2018
European Social Policy Network (ESPN)
Inequalities in access
to healthcare
A study of national policies
2018
Rita Baeten, Slavina Spasova, Bart Vanhercke and Stéphanie Coster

The European Social Policy Network (ESPN) was established in July 2014 on the initiative of the
European Commission to provide high-quality and timely independent information, advice, analysis
and expertise on social policy issues in the European Union and neighbouring countries.
The ESPN brings together into a single network the work that used to be carried out by the European
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Economic Impact of Social Protection Reforms (ASISP) and the MISSOC (Mutual Information Systems
on Social Protection) secretariat.
The ESPN is managed by the Luxembourg Institute of Socio-Economic Research (LISER), APPLICA
and the European Social Observatory (OSE).
For more information on the ESPN, see: http:ec.europa.eusocialmain.jsp?catId=1135&langId=en
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This document has been prepared for the European Commission, however it reflects the views only
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ISBN 978-92-79-94740-7
Doi 10.2767/371408
© European Union, 2018
Reproduction is authorised provided the source is acknowledged.
Quoting this report: Baeten, R., Spasova, S., Vanhercke, B. and Coster, S. (2018). Inequalities in
access to healthcare. A study of national policies, European Social Policy Network (ESPN), Brussels:
European Commission.
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Inequalities in access to healthcare A study of national policies
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Contents
PREFACE ...................................................................................................................... 5
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ........................................................ 7
1 DESCRIPTION OF THE FUNCTIONING OF COUNTRIES’ SYSTEMS FOR ACCESS TO
HEALTHCARE .......................................................................................................... 12
1.1 Health system financing .................................................................................... 12
1.2 Health coverage ............................................................................................... 15
1.2.1 Who is covered? Population covered by the statutory health system ............. 16
1.2.2 What is covered: the range of healthcare benefits ...................................... 20
1.2.3 How much is covered: user charges, excess fees and informal payments ........ 21
1.3 Voluntary health insurance (VHI) ....................................................................... 25
1.4 Availability of health services ............................................................................. 26
1.4.1 The overall supply of healthcare ............................................................... 26
1.4.2 Availability of health professionals ............................................................ 27
1.4.3 Regional disparities in health services ....................................................... 27
1.4.4 Waiting times ......................................................................................... 28
1.4.5 The role of private sector health providers and healthcare fully paid out-of-
pocket ...................................................................................................... 29
2 TACKLING CHALLENGES IN INEQUALITIES IN ACCESS TO HEALTHCARE ........................ 31
2.1 Effective access to healthcare: explaining unmet needs ......................................... 31
2.1.1 Inequalities in effective access to healthcare: the general picture .................. 31
2.1.2 Explaining unequal access: population groups ............................................ 33
2.1.3 Explaining inequalities in effective access: considering health system design ... 41
2.1.4 Wrapping up: strengths and weaknesses of healthcare systems in ensuring
access to healthcare ................................................................................... 46
2.2 Recent and planned reforms ............................................................................... 47
3 THE MEASUREMENT OF INEQUALITIES IN ACCESS TO HEALTHCARE ............................. 50
ANNEX 1: FIGURES ..................................................................................................... 55
ANNEX 2: OFFICIAL COUNTRY ABBREVIATIONS .............................................................. 57
ANNEX 3: REFERENCES................................................................................................ 58
ANNEX 4: LISTS OF BOXES, FIGURES AND TABLES ......................................................... 59
ANNEX 5: PRESENTATION OF THE EUROPEAN SOCIAL POLICY NETWORK (ESPN), JULY
2018 ..................................................................................................................... 61
A. ESPN Network Management Team and Network Core Team ...................................... 61
B. ESPN national independent experts for social protection and social inclusion............... 62

Inequalities in access to healthcare A study of national policies
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Inequalities in access to healthcare A study of national policies
5
PREFACE
The right of everyone to timely access to affordable, preventive and curative care of good
quality is one of the key principles of the recently proclaimed European Pillar of Social
Rights
1
. This means that access to healthcare should be effective for each person: it should
be provided when people need it, through a balanced geographical distribution of
healthcare facilities, professionals and policies to reduce waiting times. Costs should not
prevent people from receiving the healthcare they need. Curative care, health promotion
and disease prevention should be relevant, appropriate, safe and effective. Progress
towards this principle is currently monitored by the European Pillar of Social Rights’ Social
Scoreboard indicator on “self-reported unmet need for medical care”
2
. Promoting access
to healthcare has also been one of the core objectives — alongside achieving high quality
healthcare and financial sustainability of health systems — of the healthcare strand of the
Social Open Method of Coordination since 2004. More recently, reduction of health
inequalities, both in order to achieve social cohesion and to break the vicious circle of poor
health contributing to poverty and social exclusion, has been advocated in key European
Commission documents (including the Social Investment Package and the Annual Growth
Surveys). Member States’ health systems have received increasing attention in the
European Semester process, including through the Country-Specific Recommendations and
the Commission’s Country Reports.
Achieving universal healthcare coverage, including financial risk protection for all, is
furthermore a key target (target 3.8) of the United Nations' Sustainable Development
Goals (SDG), with a view to implementing Goal 3: ensuring healthy lives and promoting
well-being for all at all ages.
Health systems face the challenge of ageing populations and increasing demand, which
can also result from non-demographic factors such as the emergence of new (often
expensive) treatments. In some European countries, costs and waiting time remain
important barriers to accessing healthcare. Against a background of rising demand for
healthcare resources, and public budgets which are often under pressure, ensuring
universal and timely access to high quality healthcare — whilst also guaranteeing the
financial sustainability of health systems — is a challenge which requires increased efforts
to improve the efficiency and effectiveness of health systems.
According to a European Commission (2014) Communication, access to healthcare includes
the following dimensions: a) population coverage; b) affordability of healthcare (cost-
sharing); c) basket of care; and d) availability of healthcare (distance, waiting times).
These dimensions are interlinked. Thus, a lack of public healthcare coverage, or the
provision of only a limited set of services by the public health system, may result in higher
costs and affordability problems for some groups. Similarly, some types of coverage (e.g.
occupational health insurance schemes) may result in easier or faster availability of
healthcare for people in a better socio-economic position. Finally, the different dimensions
of access, in particular population coverage, may be affected by the financing structure of
healthcare
3
and by the mechanisms linking payments into the system to access to
healthcare.
People on a low income have more difficulties accessing healthcare. The share of self-
reported unmet healthcare needs (especially due to cost) is usually higher among low-
income households. However, other groups may also potentially have limited effective
access to healthcare, such as single person households or informal workers. Moreover,
people without documents do not normally have full access to healthcare.
1
Principle 16 – “Healthcare”. The full text of the European Pillar of Social Rights and various accompanying documents are available online.
2
The Social Scoreboard is available online.
3
Pooled resources for healthcare funding mostly come from general taxation, social security contributions and/or premiums for
compulsory private insurance.

Inequalities in access to healthcare A study of national policies
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The characteristics of the individual patient — such as poor literacy, language or culture,
social inhibition, isolation, lack of trust between the provider and the patient as well as
geographical mobility — can also hinder accessibility to healthcare. Inequalities in these
characteristics of the population can, to some extent, generate inequalities in access to
healthcare. While access can be affected by public policy beyond the health system —
including by policies related to income protection, education, employment and costs of
other basic services and transport — the extent to which these characteristics effectively
affect access also depends on the design and functioning of the health system and its
interaction with the characteristics of the population (EXPH 2016).
A Synthesis Report from the European Social Policy Network
With a view to supporting its analysis and forthcoming initiatives, the European
Commission asked the national experts of the European Social Policy Network (ESPN) to
describe the extent of inequalities in access to healthcare in their country, to analyse
country-specific challenges and to provide good practices.
The present Synthesis Report describes the main features of health systems enabling
access, analyses the main challenges in inequalities in access to healthcare identified in
the 35 countries under scrutiny and how they are tackled, and briefly discusses the
indicators available at national and European level on access to healthcare.
The study illustrates the main challenges and trends in national policies through examples.
Countries which have developed along similar lines are listed in brackets (e.g. AT, BE, BG)
so that the reader interested in knowing more about these can examine the 35 ESPN
national experts’ reports
4
. In producing their reports, national ESPN experts cite many
different sources in support of their analysis. References to these are not included in the
present report. Readers wishing to follow up the original sources should consult the
individual expert reports.
The report does not deal with inequalities in health per se, nor the important socio-
economic determinants outside the health system underlying these inequalities. Indeed,
education, housing, food and employment all have a crucial impact on health but are
beyond the scope of this report. Similarly, the quality of the healthcare provided, although
a crucial aspect of access, is not addressed in this report (see e.g. OECD/WHO/World Bank
Group, 2018).
The main challenges identified regarding inequalities in access to healthcare are: a)
inadequacy of the public resources invested in the health system; b) fragmented population
coverage; c) gaps in the range of benefits covered; d) prohibitive user charges, in
particular for pharmaceutical products; e) lack of protection of vulnerable groups from user
charges; f) lack of transparency on how waiting list priorities are set; g) inadequate
availability of services, in particular in rural areas; h) problems with attracting and retaining
health professionals; and i) difficulties in reaching particularly vulnerable groups. The
Synthesis report also identifies national reforms aimed at tackling these challenges and
proposes policy recommendations, at both national and EU levels.
This Synthesis Report draws on the national contributions prepared by the 35 ESPN Country
Teams
5
. It was written by Rita Baeten, Slavina Spasova, Bart Vanhercke and Stéphanie
Coster of the ESPN’s Network Core Team
6
, with helpful comments and suggestions from
the ESPN Country Teams and from colleagues in the Network Management Team
7
.
4
Here and throughout the report, the countries in brackets are provided as examples and the lists are not necessarily exhaustive.
5
For a presentation of the ESPN Network Core Team and the 35 ESPN Country Teams, see Annex 5. The 35 ESPN national experts’ reports
on inequalities in access to healthcare can be downloaded here (ESPN page on the European Commission website).
6
The authors are from the European Social Observatory (OSE, Brussels). They are grateful to Paola Signorelli (University of Milan) for
substantial graphical support.
7
We wish to thank Hugh Frazer (Maynooth University, Ireland) and Eric Marlier (Luxembourg Institute of Socio-Economic Research, LISER)
for their valuable feedback on the draft report and especially for their excellent drafting suggestions concerning the policy
recommendations.

Inequalities in access to healthcare A study of national policies
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Comments and suggestions from the European Commission are also gratefully
acknowledged
8
.
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
Summary
Based on the in-depth national contributions prepared by 35 ESPN Country Teams, the
Synthesis Report outlines the following ten key findings.
First, there is a huge variety in the amount of public resources
9
spent on healthcare in
the countries analysed, ranging from 3% of GDP in Cyprus to 9.4% of GDP in Germany.
This leads to important differences in the share of the cost of services that has to be paid
by the patient as well as to large variations in the availability and quality of services. In
some countries, public healthcare funding has been drastically reduced as a result of
expenditure cuts following the 2008 economic and financial crisis (e.g. CY, EL, ES, IS, IT,
PT). Since 2015, healthcare budgets in most of these countries have shown a slight
recovery.
Second, most countries for which the national ESPN experts stressed that their system is
underfunded (e.g. BG, CY, EE, EL, HR, HU, IE, IT, LT, LV, PL, RO, RS), perform worse
than the EU average with regard to both access to healthcare and inequalities in access
to healthcare between income groups. Indeed, underfunding leads to substantial shortages
in healthcare provision and large shares of the cost for healthcare to be paid by the patient.
Third, while a large majority of European health systems cover nearly the whole
population for a comprehensive basket of healthcare benefits, in some countries, a
significant percentage of the population is not covered by the statutory health system,
ranging from 5% in Hungary to more than 20% in Cyprus. But even in countries providing
nearly universal population coverage, some specific population groups may fall through
the safety net. Groups not mandatorily covered include, in some countries: non-active
people of working age without entitlement to cash social protection benefits, some people
in non-standard employment, some categories of self-employed, people who did not
contribute a sufficient number of years to the system, undocumented people and asylum
seekers.
Fourth, the high out-of-pocket payments (OOP)
10
for medicines, but also dental
care and mental healthcare, are a cause of concern in most European countries. In
particular, in many countries vulnerable groups are not protected from high user charges
for pharmaceuticals, and pharmaceuticals are often exempted from annual caps on user
charges. This may have an important impact on the effectiveness of the healthcare
provided.
Fifth, the outcome with regard to access to healthcare can be quite different
between countries spending similar amounts of public money on healthcare. Thus,
some countries with below EU average public spending on healthcare as a proportion of
GDP (e.g. CZ, ES, UK) perform rather well with regard to access to healthcare and
preventing inequalities in access to healthcare among income groups. In many of the well-
performing systems, user charges are relatively low or healthcare is free at the point
of use.
8
As mentioned above, the report reflects the views only of the authors and the Commission cannot be held responsible for any use which
may be made of the information contained therein.
9
Public resources include both general taxation and compulsory insurance contributions.
10
Different forms of OOP exist. They include: 1) direct payments: payments for goods or services that are not covered by any form of third-
party payment; 2) cost-sharing (user charges): a provision of health insurance or third-party payment that requires the individual who is
covered to pay part of the cost of the healthcare received; 3) excess fees: payments due on top of the regulatory defined user charges, for
healthcare provided by health providers who are free to set their tariffs; and 4) informal payments: unofficial (under-the-table) payments
for health goods or services (own elaboration based on Rechel, Thomson and van Ginneken (2010)).

Inequalities in access to healthcare A study of national policies
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Sixth, inequalities in access to healthcare do not seem to be linked to the model
of health system funding. Health systems can be broadly categorised into three models,
depending on how they are funded: National Health Service (NHS); Social Health Insurance
(SHI) or Private Health Insurance systems.
11
Well-performing countries can be found
among all three models. This suggests that the performance of systems in terms of
safeguarding access is, instead, related to the country-specific details of the
organisation of healthcare provision and the way in which vulnerable groups are
protected from user charges within each of the systems.
Seventh, while in many countries the provision of healthcare facilities is generally
considered to be sufficient by the ESPN country experts, in many others the supply of
health services is reported to be inadequate: this is referred to as an implicit form of
rationing. Many countries experience shortages of health professionals and, in
particular, reduced numbers of professionals working in the publicly funded system.
Factors which make working in the public system less attractive include poor wages and
working conditions. Serious shortages of healthcare, particularly primary care, provision
have frequently been reported in rural areas.
Eighth, waiting lists are an issue in a large majority of European countries. In some
countries there are official waiting lists for specific treatments, while in many others there
is a lack of transparency on priority-setting, or no monitoring of waiting times. According
to many ESPN country experts, patients can bypass waiting times in the public sector
if they (first) consult the specialist privately and therefore pay additional fees (e.g. AT, ES,
FI, LT, MT, PL, SI). Informal (under-the-table) payments by the patient to physicians,
which are common practice in several countries, are also made in order to bypass waiting
lists or to have access to healthcare of better quality (e.g. BG, EL, HU, LT, LV, RO, RS, SI,
TR).
Ninth, many ESPN experts warn that (the growth in) voluntary and occupational health
insurance may exacerbate inequalities in access to healthcare, particularly when the
schemes are used to “jump the queue” – for example, by those in better employment
situations. All these practices thus lead to access to healthcare based on ability to pay.
They may also lead to worse availability of public healthcare if doctors leave the publicly
funded sector to work in the private sector.
Finally, and crucially, several population groups have significant difficulties in
accessing healthcare. The lowest income quintiles are among the most
disadvantaged groups in terms of effective access to healthcare. The most striking example
is Greece, where the lowest income quintile reports 35.2% of unmet needs and the highest
only 1% in 2016. Women also face many more difficulties in access to healthcare than
men. Access to healthcare can also be hindered by residence status and ethnicity. Roma
populations have been reported to be among the most vulnerable with regard to access to
healthcare (e.g. BG, HU, HR, MK, SI, SK). Access to healthcare for migrants and in
particular asylum seekers, refugees and undocumented migrants has also become a
particularly acute issue.
Conclusions
This report explores inequalities in access to healthcare in 35 European countries. The
overall conclusion is that, while the general direction of travel is towards improved access
to healthcare, important inequalities in access to healthcare persist, both between and
within countries; and large shares of the EU population, in particular vulnerable groups,
face multiple hurdles and therefore do not obtain the care they need.
The ten key findings of the report can be summarised as follows: a) there is a huge variety
in the amount of public resources spent on healthcare in the 35 countries analysed; b)
11
National Health Service (NHS) systems are mainly funded through general taxation. Social Health Insurance (SHI) systems are financed by
a mix of social contributions and general taxation. In Private Health Insurance (PHI) systems, premiums are directly paid by the insured
members to the insurance company on an individual basis or are paid by the employer and deducted from the salary of the employee.

Inequalities in access to healthcare A study of national policies
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most of the underfunded systems perform worse than the EU average with regard to access
to healthcare; c) in some countries, a significant percentage of the population is not
covered by the statutory health system; d) high out-of-pocket payments, in particular for
pharmaceuticals, are a cause of concern in most European countries; e) between countries
spending similar amounts of public money on healthcare, the outcome with regard to
access to healthcare can be quite different; f) inequalities in access to healthcare are linked
to the country-specific detailed organisation of healthcare provision and the way in which
vulnerable groups are protected from user charges, rather than to the type of health
system; g) the supply of health services is inadequate in many countries (esp. shortages
of health professionals and in rural areas); h) waiting lists are an issue in a large majority
of European countries; i) the growth in voluntary and occupational health insurance may
exacerbate inequalities; and j) several population groups (which include the lowest income
quintiles, women, ethnic minorities and migrants) have significant difficulties in accessing
healthcare.
The main challenges identified regarding inequalities in access to healthcare are: a)
inadequacy of the public resources invested in the health system; b) fragmented population
coverage; c) gaps in the range of benefits covered; d) prohibitive user charges, in
particular for pharmaceutical products; e) lack of protection of vulnerable groups from user
charges; f) lack of transparency on how waiting list priorities are set; g) inadequate
availability of services, in particular in rural areas; h) problems with attracting and retaining
health professionals; and i) difficulties in reaching particularly vulnerable groups.
In several countries that do not cover the whole population, important reforms are
underway to provide improved coverage. Yet reforms are often very slow, opposition from
vested interests may be substantial and financial means are often insufficient to ensure
proper implementation.
A substantial increase in unmet needs was noticed during the crisis years: from 3% of the
respondents reporting unmet needs for medical care in 2009 to 3.6% in 2014. This may
be explained by the austerity policies in many countries, loss of entitlement for some
groups, reduced household budgets available for healthcare (due to rising unemployment
and increased costs for other basic services) and, at the same time, an increasing need for
healthcare. Since 2015, a gradual recovery has taken place, and in 2016, unmet need, at
2.5%, is for the first time below the level of 2008. However, in some countries the situation
is deteriorating further.
Access to healthcare is generally considered as a human right
12
and has been recently
enshrined in the European Pillar of Social Rights. The analysis contained in this report may
provide input for policy discussion at country and EU level on how to better guarantee this
right for the people of Europe.
Recommendations
It is hoped that the recommendations formulated below can provide a useful framework
for the European Commission and the Member States, to help them assess and enhance
their efforts to implement the European Pillar of Social Rights principle on access to
healthcare. These recommendations are based upon an analysis of the 35 ESPN country
reports and further analysis by the ESPN Network Core Team.
a) Recommendations to countries
The following set of recommendations are issued to the Member States. It should be noted
that the best-performing countries have already implemented many of these
recommendations, but all European countries have some areas where improvements are
needed.
12
See e.g. Art. 25(1) of the United Nations Universal Declaration of Human Rights (1948) and Art. 35 of the Charter of Fundamental Rights
of the EU.

Inequalities in access to healthcare A study of national policies
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Financing of health systems
 First and foremost, sufficient public funding, from general taxation and
compulsory health insurance contributions, should be allocated to the statutory
health system, in order to meet the health needs of the population.
Health coverage
 The whole population should be covered for a comprehensive range of
healthcare benefits. Efforts are needed to ensure that all people, including those
on low incomes or in precarious or unstable jobs, are covered by the health system.
 The inclusion of undocumented people, asylum seekers and homeless
people in the system is strongly advisable and may well come at only a marginal
additional cost.
 Differences in coverage lead to unequal access to healthcare. The range of
services covered should be uniform for all people and include cost-effective
hospital care, outpatient primary and specialist care and pharmaceutical products.
Coverage for mental healthcare and dental care should be improved.
User charges
 User charges for healthcare must not hamper effective access to healthcare. The
annual level of user charges should be capped at a sufficiently low level and
should take into account household income. Vulnerable groups, such as low-
income earners, patients with chronic conditions or infectious diseases, beneficiaries
of certain social benefits, pregnant women, children and old age pensioners, should
be protected from user charges.
 In particular, coverage for pharmaceutical products should be substantially
improved in many countries and the annual amount of user charges for
pharmaceutical products should be capped.
Availability of services
 In order to shorten waiting lists for medical services, countries should invest
sufficiently in healthcare provision and ensure a sufficient supply of health
professionals. It is therefore necessary in many countries to improve the working
conditions of healthcare staff and ensure sufficient pay for health
professionals working in the publicly funded system.
 To avoid patients jumping the queue by first consulting private doctors or providing
informal under-the-table payments, transparency on priority-setting in
waiting lists is crucial.
 To prevent practitioners having an incentive to prioritise patients who pay more,
tariffs for statutorily covered healthcare should be uniform, irrespective of
whether or not the health professional is contracted by the statutory system.
 Particular efforts should be made to ensure access to healthcare in remote and
sparsely populated areas. Health professionals should be incentivised to settle
there. Countries should invest considerably in integrated primary care services,
not only, but in particular, in rural areas.
Voluntary health insurance
 Countries should prioritise investing available public resources in improving the
statutory health system and should not financially support — directly or
indirectly — voluntary health insurance schemes.

Inequalities in access to healthcare A study of national policies
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Initiatives targeting vulnerable groups
 A proactive approach is needed to reach particularly vulnerable groups, such
as homeless people, drug addicts, ethnic minorities, Roma, asylum seekers and
refugees. Targeted solutions should be set up to ensure access to healthcare for
these minorities, such as regular health campaigns, preventive actions and cultural
mediators. Specific information campaigns are needed to inform them about their
rights.
b) EU-level recommendations
While fully respecting the competencies of the Member States with regard to the
organisation and funding of their health systems, the EU should support Member States in
their efforts to reduce inequalities in access to healthcare, in particular by collecting and
analysing comparative data related to access to healthcare, by monitoring progress, by
organising exchanges of good practice and by flagging Member States lagging behind in
the context of the European Semester process.
The following initiatives are therefore recommended:
 the EU’s Social Protection Committee (SPC) and the European Commission should
develop a roadmap for the implementation of Principle 16 of the European
Pillar of Social Rights, which states that “Everyone has the right to timely access
to affordable, preventive and curative healthcare of good quality”;
 the SPC and its Indicators Sub-Group have an important role to play in monitoring
access to healthcare in Member States and in sounding an alert when the
situation is deteriorating. An appropriate Joint Assessment Framework (JAF) on
healthcare should be developed and used as an evidence-based policy instrument
in dialogue with national authorities;
 the European Commission should strengthen the monitoring and reporting on
inequalities in access to healthcare in the European Semester process, with
the use of Country Reports and Country-Specific Recommendations for those
countries lagging behind. Countries lagging behind with regard to the
percentage of GDP spent on healthcare should be flagged;
 EU funding (notably the European Social Fund+ [ESF+]) should be used to
improve access to healthcare, in particular for vulnerable groups;
 the Commission should foster the exchange of experience and good practice
between Member States on policies promoting equal access to healthcare,
including through peer reviews and the collection of case studies. The Commission
and the SPC should set up a peer review on initiatives specifically aimed at
reaching ethnic minorities, in particular the Roma population, and promoting
targeted solutions to improve access to healthcare, such as health campaigns and
cultural mediators. The results could be used in the National Roma Integration
Strategies;
 the Commission should invite the Expert Group on Health System Performance
Assessment (HSPA), made up of representatives of EU Member States and
international organisations, to focus discussions on inequalities in access to
healthcare;
 the quality and comparability of the measurement of access to healthcare
should be improved in EU surveys, so as to better capture and monitor national
situations and strengthen comparability across countries. Measurement of access
to prescribed pharmaceutical products should be included in these surveys.

Inequalities in access to healthcare A study of national policies
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1 DESCRIPTION OF THE FUNCTIONING OF COUNTRIES’
SYSTEMS FOR ACCESS TO HEALTHCARE
This section provides an overview of the main features of the health systems, relevant for
ensuring access to healthcare and addressing inequalities in this area, in the 35 countries
analysed. Section 1.1 discusses how resources are generated for the health system.
Section 1.2 discusses how the countries perform on the different dimensions of health
coverage. Voluntary health insurance is discussed in Section 1.3 and the availability of
health services is addressed in Section 1.4.
1.1 Health system financing
Healthcare in European countries is financed through a mix of financing schemes. These
include: first, government spending generated through general taxation; second,
compulsory health insurance generated through employer and employee contributions
and/or premiums paid to private health insurance companies; third, out-of-pocket (OOP)
payments by households and fourth, voluntary health insurance (VHI) schemes.
Government spending and compulsory health insurance are the sources of public spending
for healthcare, implying strong solidarity mechanisms and regulation. Private health
spending consists of OOP and VHI.
Different forms of OOP exist. These include: a) direct payments: payments for goods or
services that are not covered by any form of third-party payment; b) cost-sharing (user
charges): a provision of health insurance or third-party payment that requires the
individual who is covered to pay part of the cost of the healthcare received; c) excess fees:
payments due on top of the regulatory defined user charges, for healthcare provided by
health providers who are free to set their tariffs; and d) informal payments: unofficial
(under-the-table) payments for health goods or services
13
.
Figure 1: Current health expenditure by type of financing, 2014
Source: OECD/EU (2016), Health at a Glance: Europe 2016; * ESPN countries not included in the dataset: LI.
Note: Countries are ranked by government schemes and compulsory health insurance as a share of current health expenditure. 1 Includes
investments.
Voluntary health insurance can cover healthcare benefits not included in the statutory
healthcare basket; as well as user charges or a greater choice of providers. In some
countries, in particular in those where such schemes are important to ensure access to
13
Own elaboration based on Rechel, Thomson and van Ginneken (2010).

Inequalities in access to healthcare A study of national policies
13
healthcare for specific groups, they may involve some solidarity elements, regulation and
direct or indirect public funding (e.g. CY, FI, FR, HR, HU, IE, LV, SI).
Overall, nearly 80% of health spending in the countries analysed is funded through general
taxation or compulsory health insurance schemes, 15% by households through OOP, and
5% through VHI. The rate of OOP spending nevertheless reaches more than 25% in some
countries (e.g. BG, CH, CY, EL, HU, LT, LV, MK, MT, RS, PT) and is as high as 50% in
Cyprus. VHI funds more than 10% of health spending in Ireland, France, and Slovenia (See
Figure 1).
Adequate health system funding is fundamental to securing the required levels of quality
services to meet the population’s needs. Inadequate public funding for the health system
creates and exacerbates barriers to access (SPC 2016).
There is a huge variety in the public resources made available to the health systems in the
countries analysed, ranging from 3% of GDP in Cyprus to 9.4% of GDP in Germany (see
Figure 2)
14
.
Figure 2: Health expenditure as a share of GDP, 2015 (or nearest year)
Source: OECD/EU (2016), Health at a Glance: Europe 2016; 1 Includes investments; 2 OECD estimate; * ESPN countries not included in the
dataset: LI.
Health systems can be broadly categorised into three models, according to how they are
funded: National Health Service (NHS) systems; Social Health Insurance (SHI) systems or
Private Health Insurance (PHI) systems (see Table 1). National Health Service systems are
primarily tax-funded (e.g. CY, DK, ES, IE, IS, IT, LV, MT
15
, NO, PT, SE, UK).
Social Health Insurance systems are financed by a mix of social contributions and general
taxation (e.g. AT, BE, BG, CZ, EE, FR, HR, HU, LT, LU, MK, PL, RO, RS, SI, SK, TR), with
the state — in principle — contributing to the system for non-contributing groups such as
children and pensioners (Section 1.2). The share of the insured population not directly
contributing to the system can be very high: from 30% in Austria up to 60% in the Czech
Republic. Finland and Greece combine a tax-funded NHS model with compulsory social
health insurance, and in Cyprus a systemic reform is being implemented, shifting from an
NHS system toward a SHI system.
14
The data include healthcare-related long-term care expenditure.
15
In Malta, economically active persons pay a percentage of their income to cover social security. The money thus collected is however not
kept in a specific fund but goes into a consolidated state-run fund, from which money is allocated to cover social security, pensions and
health expenses.
9.4 9.3 8.9 8.7 8.6 8.0 7.9 7.8 7.7 7.3 6.8 6.6 6.5 6.4 6.3 6.0 6.0 5.8 5.6 5.0 5.0 4.8 4.7 4.5 4.5 4.4 4.0 3.4 3.0
8.5 7.8 7.2 6.4
4.1 4.0
11.1
11.1
10.6
10.8
11.0
10.4
10.4
9.9
9.8
9.6
9.1
9.6
9.4
7.5
9.0
8.4
7.2
8.9
7.0
6.6
8.2
6.3
7.0
6.3
8.3
6.5
5.0
5.6
6.8
9.9
11.5
8.8
10.3
6.5
5.2
0
2
4
6
8
10
12
14
DE
SE
DK²
NL
FR²
BE²
AT²
EU28
UK²
FI
IT²
MT¹ ²
IE²
CZ²
ES²
SI
LU
PT
SK²
HR²
EL²
EE
HU²
PL²
BG²
LT²
RO²
LV²
CY²
NO
CH
IS¹
RS¹
MK¹
TR²
% GDP Government/compulsory Private/voluntary

Inequalities in access to healthcare A study of national policies
14
In a few countries, a mandatory Private Health Insurance (PHI) system is implemented. In
PHI systems, private health insurers play a pivotal role in providing a statutory defined
package of benefits through compulsory health insurance (e.g. CH, LI, NL). Premiums are
directly paid by the insured members to the insurance company on an individual basis, or
are paid by the employer and deducted from the salary of the employee. Germany has a
SHI and for some specific groups a compulsory PHI.
Table 1: Models of health systems in Europe
NHS systems
SHI systems
PHI systems
CY1, DK, ES, IE, IS, IT, LV1, MT,
NO, PT, SE, UK
AT, BE, BG, CZ, EE, FR, HR,
HU, LT, LU, MK, PL, RO, RS, SI,
SK, TR
CH, LI, NL
EL, FI
Mixed systems NHS/SHI
DE
Mixed system SHI/PHI
Source: authors’ own elaboration drawing on ESPN country reports. 1 Country in transition towards a SHI system (see Section 2.2).
The share of the state contribution to social health insurance (SHI) based systems varies
a great deal, from 12.6% of the health insurance budget in Estonia to 40% in Luxembourg
and Lithuania. In countries where the state contribution for the non-contributing groups is
very low (e.g. BG, EE, HR, PL), the health systems run a deficit: in these countries,
healthcare for non-contributing groups has to be financed from resources collected via
employer/employee contributions. In some countries, plans have been made to increase
the state contribution for non-contributing groups (e.g. CZ, EE).
ESPN experts in many countries underline that the statutory health system in their country
is underfunded (e.g. BG, CY, EE, EL, HR, HU, IE, IT, LT, LV, PL, RO, RS), and this low level
of funding is reported to be one of the main reasons for the underdevelopment of the
health system. This typically results in a limited number of contracts with health providers,
underfunding of hospitals, limited supply of medical services and in some cases high out-
of-pocket payments.
In some countries where the system is structurally underfunded, public funding has
gradually increased or governments have decided to increase public funding in the near
future (e.g. EE, LV, PL, RO). In an attempt to broaden the funding base for the system,
some of the systems that are underfunded are currently in a transition from tax-funding
to a contribution-based SHI (e.g. CY, LV). In Serbia, however, the compulsory contribution
rate was reduced in 2013 from 12.3% to 10.3%, which led to a significant drop in the
revenue of the health insurance fund.
In several countries, public healthcare funding has been drastically reduced as a result of
expenditure cuts following the economic crisis and, for some of these countries, due to the
implementation of the Economic Adjustment Programmes agreed with the EU lenders.
Since 2015, healthcare budgets in most of these countries have shown a slight recovery
(e.g. CY, EL, ES, IE, IS, IT, PT). Box 1 illustrates this point.

Inequalities in access to healthcare A study of national policies
15
Box 1: The impact of the crisis on public funding of healthcare in some countries
In Greece, healthcare funding was reduced by approximately 36.5% during the period 2009-
2016. In absolute numbers, total public expenditure on health decreased from €16.1 billion in
2009 to €9 billion in 2016, whereas total private funding decreased from €7 billion in 2009 to
€5.6 billion in 2016. Total funding of health expenditure followed a downward trend until 2014,
while a slight recovery can be observed in 2015 and 2016.
In Iceland, healthcare expenditure fell from 9.3% of GDP in 2007 to 8.6% of GDP in 2016
(public 7.1% and private 1.5%).
In Ireland, financing of the Health Service Executive (HSE) fell by 22% between 2009 and
2013, amounting to almost €3.3 billion less in public funding. The 2015 budget was the first in
seven years where health expenditure was not cut, and the country has seen reinvestment in
health expenditure since then.
In Italy, the annual growth rate of expenditure on public healthcare in real terms was on
average -2.4% between 2010 and 2014.
In Spain, the financial resources devoted to healthcare decreased by 13% between 2010 and
2014. Although public healthcare expenditure increased by 3.5 billion in 2015 and by an
additional €600 million in 2016, the process of fiscal consolidation in the healthcare sector
continues. Public healthcare expenditure, which amounted to 6.8% of GDP in 2009, fell to 5.9%
in 2017, and is to be further reduced to 5.6% by 202016.
Source: ESPN country reports
1.2 Health coverage
Health coverage has three dimensions: the share of the population entitled to publicly
financed health services (population coverage), the range of health services covered
(benefit package), and the extent to which people have to pay for these services at the
point of use (user charges) (WHO 2010). Services that are wholly or partially excluded
from public provision must be paid for by patients, either through direct private spending
or through the purchasing of voluntary health insurance. Universal health coverage, as
defined in the United Nations' Sustainable Development goals, implies that the whole
population is covered for a broad range of health services and products and that they are
covered for the full cost.
Figure 3 provides a visual image of the three dimensions of health coverage. The small
cube presents the actual coverage (“Current pooled funds”), while the spaces between the
small and the large cube represent the gaps in coverage between actual coverage and
universal health coverage, in terms of the population, services and costs covered.
16
Plans to further reduce healthcare expenditure to 5.6% by the year 2020 were made by the former government. The new government
(June 2018) has committed itself to reverse the cuts made to healthcare budgets and to bring these back to levels previous to the fiscal
consolidation measures adopted in 2010.

Inequalities in access to healthcare A study of national policies
16
Figure 3: The dimensions of health coverage
Source: WHO 2010.
In this section, we assess, based on the ESPN experts’ country reports, how the 35
European countries under scrutiny perform on each of the three dimensions of health
coverage. We therefore discuss who is covered (Section 1.2.1); what is covered (Section
1.2.2); and how much is covered (Section 1.2.3).
1.2.1 Who is covered? Population covered by the statutory health system
Covered groups
A large majority of European health systems provide nearly universal population coverage
for a defined basket of healthcare benefits (for the range of benefits covered, see Section
1.2.2) (e.g. AT, BE, CH, CZ, DE, DK, ES, FI, FR, HR, HU, IE, IS, IT, LI, LT, LU, LV, MT, NL,
NO, RS, SE, SI, SK, UK) (see Figure 4).

Inequalities in access to healthcare A study of national policies
17
Figure 4: Percentage of the population covered for a defined set of services, 2014 (or nearest year)
Source: OECD/EU (2016), Health at a Glance: Europe 2016; * ESPN countries not included in the dataset: LI.
In principle, the systems that are tax-funded (NHS systems) provide universal population
coverage based on residency (e.g. DK, ES, IS, IT, LV, MT, NO, PT, SE, UK). However, this
is not the case in Cyprus, where access to public healthcare is based on income criteria.
Groups which are not covered may access public health services but must pay for the
healthcare out of their own pocket, while an annual means-tested ceiling on out-of-pocket
payments applies. Coverage may be extended to some categories of non-residents/citizens
such as students and undocumented migrants (e.g. MT, PT).
In principle, systems based on Social Health Insurance (SHI) cover people who contribute
to the system. In these systems, people in gainful employment (employees and self-
employed) are therefore covered. In some countries, pensioners (e.g. EL, HR
17
, MK, PL),
recipients of replacement benefits (e.g. LU) and those not employed but able to work (e.g.
17
In Croatia, this only applies to pensioners with an income above a certain threshold.

Inequalities in access to healthcare A study of national policies
18
HU, LT, LU, MK), as well as their spouses (e.g. HU, LT), have to pay mandatory health
insurance contributions. For pensioners, contributions may also be paid by the pension
funds (e.g. RS, SI). Premiums for households on a low income may be fully or partially
paid by the public authorities (e.g. LU, TR).
In practice, however, most SHI systems provide nearly universal population coverage, by
extending insurance coverage to non-contributing groups. These include: dependent family
members of the contributing persons, such as (studying) children (e.g. AT, BE, BG, DE,
EE, EL, HR, HU, LI, LT, LU, MK, PL, RO, RS, SI, SK, TR) and partners (e.g. AT, BE, DE, EL,
MK, PL, RO, SI, SK, TR), those receiving social insurance benefits, such as pensioners (e.g.
AT, BE, BG, DE, EE, HR, HU, LT, RS, SK, TR) and the unemployed (e.g. AT, BE, BG, DE,
EE, EL, HR, HU, LT, PL, RS, SI, SK), recipients of social assistance benefits (e.g. disabled
people) (e.g. AT, BE, DE, EE, EL, HR, HU, LT, LU, PL, RO, SI, SK, RS), caregivers and
personal assistants to severely disabled citizens (e.g. RO, SI, SK). In some of the social
insurance-based systems, entitlement to health insurance coverage is based on permanent
residence (e.g. CZ, FR). In principle, the state pays the contribution for the non-
contributory groups (see Section 1.1)
In health systems based on mandatory private health insurance (PHI), premiums are
directly paid by the insured members to the insurance company on an individual basis or
are paid by the employer and deducted from the salary of the employee (e.g. DE,
18
LI,
NL). They may also be paid by the unemployment insurance (e.g. LI). Premiums are as a
rule not related to income. In the Netherlands, insured persons additionally pay an income-
related contribution through their employer. In principle, insurers must accept all
applicants (open enrolment) (e.g. CH, LI, NL). Whilst in some of these countries all persons
covered by the same insurer pay the same premium regardless of age, gender and health
status (“community rating”) (e.g. LI, NL), in others rates may be based on the individuals’
health risk at the time of the conclusion of the contract (e.g. DE). Differences in the levels
of premiums between insurers may also be subject to limits (e.g. NL). In Switzerland,
premiums are fixed by the Cantons and there is a large variation in premium levels between
them. Children and spouses with no income have to be insured individually in all these
countries (e.g. CH, DE, LI, NL). Reduced premiums may apply to children (e.g. CH) and
young adults (e.g. CH, LI) as well as low income earners (e.g. NL). Alternatively, the state
may also pay the premiums for children (e.g. LI, NL) and subsidise the premium for lower
income groups (e.g. CH, LI). The premiums for vulnerable groups, such as asylum seekers,
may be covered by social assistance (e.g. CH, LI). Since the PHI scheme was introduced
in Switzerland (1996) and the Netherlands (2006), both premiums and national health
expenditure have increased constantly. In Liechtenstein, the state contribution has been
steadily decreasing since 2010, whilst the PHI premium contributions have increased.
In some countries, different schemes of statutory coverage exist for different population
groups (see Box 2).
18
In Germany, this only applies to people above a certain income threshold who choose not to opt into the SHI.

Inequalities in access to healthcare A study of national policies
19
Box 2: Different schemes of statutory coverage for different
population groups: within-country variation
In Austria, particular social groups are insured with a specific fund and therefore face user
charges — for instance the self-employed, farmers and civil servants.
In Germany, most people are insured in the SHI system. However, tenured civil servants, the
self-employed and employees whose gross wages exceed a defined threshold may opt for
private health insurance or choose to join the SHI system. The benefit package in the PHI is
not fully standardised and the individuals may partially choose the range of benefits to be
included in the individual scheme.
In Greece, in 2016, health coverage was extended to the whole population, including uninsured
groups such as the unemployed. However, uninsured persons have access only to public health
services, while insured persons also have access to private contracted providers, on a cost-
sharing basis.
In Ireland, 54% of the population (in particular those on higher incomes) are, under the
statutory system, only entitled to hospital care.
In Liechtenstein, the Netherlands and Switzerland, all three countries with mandatory PHIs,
individuals have a certain level of choice in their insurance policy. They can opt for a policy with
lower insurance premiums but higher deductibles, i.e. the cost of healthcare to be fully paid by
the patient, before the health insurance kicks in. Individuals may furthermore choose between
policies with more or with less free choice of providers. In the Netherlands, individuals may
choose any insurer, while many employers, sports clubs and unions offer access to discounted
collective insurance.
In Spain, specific categories of public employees and their dependent family members have
their own specific social health insurance scheme (more than 2 million people in 2016), which
allows them to choose between healthcare provided by the public system, or by private
healthcare providers. Most of them have opted for private health insurance. Civil servants from
the central government hired after January 2011 can no longer join this system.
Source: ESPN country reports
Groups which are not covered
While most European health systems provide nearly universal population coverage, in
some countries more than 5% of the population is not covered by the statutory health
system (e.g. BG, CY, EE, HU, IE, LT, PL, RO, SK, TR) (see Figure 4). Cyprus has the highest
score, with nearly 20% of the population not covered for healthcare. But even in countries
with nearly universal population coverage, some specific population groups may fall
through the safety net.
Groups not mandatorily covered include in some countries: non-active people of working
age without entitlement to cash social protection benefits
19
(e.g. AT, BE, BG, EE, RO, TR);
specific categories of people in non-standard employment and precarious jobs (e.g. AT,
DE, EE, PL); some categories of self-employed (e.g. EE, RO, TR); people performing
undeclared work (e.g. BG, EE, PL, RO, RS, TR); undocumented people (e.g. AT, BE, CY,
DK, ES
20
, FI, FR, HR, LU, NO, UK); asylum seekers (e.g. DE
21
); some categories of migrants
(e.g. CY, CZ, MT); and finally, people who have not yet contributed a minimum number of
years, including adolescents entering the labour market (e.g. CY). Continuity of insurance
coverage has been raised as an issue by the Estonian ESPN experts: in 2015, 11% of the
population aged 20-64 were covered for less than 11 months per year. This affects mainly
those in unstable employment situations.
19
If they are not covered as dependent family members.
20
The new government reversed the exclusion of undocumented migrants from healthcare in September 2018, going back to a strictly
residence-based entitlement logic.
21
During the first 15 months of their stay in Germany.

Inequalities in access to healthcare A study of national policies
20
A number of ESPN experts mention that some people are not paying their compulsory
insurance contributions (e.g. BG, EE, HU, RS, TR and to a lesser extent HR) and that there
are an increasing number of people on atypical contracts (e.g. EE, PL), which may explain
the relatively high or increasing rates of people not covered for healthcare in their country.
Furthermore, the relatively low coverage rate in some countries may be (partially)
explained by people working abroad (e.g. BG, EE, LT, LU, RO, SK) or working for
international institutions with a different health insurance regime (e.g. LU). In Serbia, an
increasing number of employers (including public companies) do not pay the health
insurance contributions for their employees. In the City of Belgrade 47,000 employees
were not able to exercise their right to healthcare in 2016 as their employers did not pay
health insurance contributions.
1.2.2 What is covered: the range of healthcare benefits
The range of benefits fully or partially covered by the health system is usually
comprehensive, including prevention, outpatient primary and specialist care as well as
hospital care (e.g. AT, BE, BG, CY, DE, DK, EE, EL, ES, FI, FR, HR, HU, IS, IT, LI, MT, NL,
NO, PL, PT, RO, RS, SI, SK, TR, UK). In Ireland, however, over half of the population
covered, in particular those on higher incomes, are only covered for hospital care, and in
Latvia the range of benefits covered is relatively limited. Nevertheless, even services
included in the benefit package may be inaccessible if they are not available in sufficient
numbers. We will discuss the availability of health services in Section 1.4.
Most dental care may be excluded from the benefit package (e.g. CH, IT, LI, LV) and be
only — sometimes partially — covered for specific groups, such as children or the
chronically ill (e.g. DK, IS, LV, MT, NL, NO, PT, RO, RS, SE). Outpatient psychological
services (e.g. BE, IS) and outpatient physiotherapy and rehabilitation (e.g. IS, LV, NL),
may also be excluded from the range of benefits. While over-the-counter pharmaceuticals
22
are in principle not covered by health insurance in all of the countries studied, in some
countries, patients pay the full cost of prescription pharmaceuticals — with exemptions for
some specific groups such as the chronically ill (e.g. IS, NO, SE), or with the exception of
medicines included in a positive list, which are provided for free (e.g. MT). An annual cap
on OOP may nevertheless apply for pharmaceuticals (e.g. IS, NO, SE). Some medical
devices, such as prosthetics, orthodontics, glasses or hearing aids, may also be excluded
from the statutory benefit package (e.g. CY, CZ, EE, LV, NL).
If patients wish to access health services and products which are not covered by the benefit
package, they have to fully pay for them out of pocket, or coverage may be provided
through VHI.
In most countries, groups which are not covered by the statutory system only have access
to urgently necessary healthcare (e.g. AT, BE, BG, DE, DK, EE, EL, ES, FI, HU, IE, LT, NL,
RO, SI, SK, UK) and often also to some types of preventive care, in particular for infectious
diseases (e.g. EE, ES, IE, RO), and pregnancy/maternity care (e.g. BG, DE, ES, IE, RO)
23
.
The concept of “emergency care” is often subject to interpretation, and in some countries
there are geographical differences in how the relevant legislation is interpreted (e.g. ES,
FI).
Some countries, in particular those where important shares of the population are not
covered, provide some additional access to healthcare for the uninsured, which may include
free access to primary care (e.g. PL, RO, TR) or hospital care (e.g. BG).
22
Medicines sold directly to a patient without a prescription from a health professional, as opposed to prescription drugs, which may be
sold only to consumers possessing a valid prescription.
23
Access to urgently necessary healthcare is in principle provided from an ethical perspective and emerges from the duty to assist
someone in need and to provide healthcare in life- or organ threatening situations. Preventive care for infectious diseases may be provided
from a public health perspective, to avoid spreading the disease.

Inequalities in access to healthcare A study of national policies
21
1.2.3 How much is covered: user charges, excess fees and informal payments
If the full cost of healthcare is covered by the public system, patients do not have to pay
user charges. In other circumstances, patients will have to bear part of the costs. In this
section we explore the different aspects of user charges policies. We will first discuss the
general policies in the countries under scrutiny, then the user charges that apply to specific
services and products, and finally, the provisions to protect vulnerable groups from
prohibitive user charges. We wrap up the section by discussing excess fees and informal
payments.
User charges: general policies
In most countries, user charges apply to some health services and products (see sub-
section on coverage of specific health services and products below). However, there are
substantial differences in the general approach to user charges. In many countries, health
services covered by the statutory health system are predominantly available free at the
point of use, while in others, cost-sharing applies for most inpatient and/or outpatient care
services (see Table 2). For some examples on levels of user charges, see Box 3.
Table 2: General policies on user charges in Europe
Health services predominantly free at
the point of use
Cost-sharing for most inpatient and/or
outpatient health services
AT, CZ, CY, DK, EL, ES, HU, LI, LT, MT, PL, RO,
SK, UK
BE, BG, CH, DE, EE, FI, FR, HR, IE, IS, IT, LU, LV,
MK, NL, NO, PT, RS, SE, SI, TR
Source: authors’ own elaboration drawing on ESPN country reports.
An annual cap on user charges, set per household or insured person, applies in many
countries (e.g. AT, BE, CH, DE, FI, HR, IE, IS, LU, LV, MK, NO, RS, SE, SI). Above this
threshold, the patient does not pay any further user charges. The level of the cap can vary
according to income, the health status or age of the person insured (e.g. BE, CZ, DE, DK,
IS, RS). There is a huge variation in the maximum annual amount to be paid by the patient
between countries, ranging from €110 in Sweden to €569 in Latvia (see also Box 3).
Municipalities may (e.g. FI, SE) opt to apply lower cost-sharing rates or may provide the
relevant service free of charge. In some countries, extra charges may apply for extra
services (e.g. a better room) from contracted healthcare providers (e.g. BE, HU, SK).
In countries with statutory private health insurers (PHI), high deductibles may apply (e.g.
CH, DE, LI, NL) for insured persons who have opted to pay a lower insurance premium.
This means that a defined annual amount of healthcare costs must be fully borne by the
patient before the health insurance kicks in and covers the remaining costs. As an example,
in Switzerland, a mandatory deductible up to a maximum annual amount applies. On top
of this, individuals can opt for a voluntary deductible which can vary between €300 and
€2,150 per year. About 60% of individuals opt for such a deductible in exchange for lower
insurance premiums. In Liechtenstein, the voluntary deductible can be up to €4,340. In
the Netherlands, the costs of general practitioner (GP) consultations, maternity care and
healthcare for children under 18 are exempted from the mandatory deductible. Private
insurers can furthermore offer a “bonus” to those who have not used any health services
during a year (e.g. NL).
Increases in user charges were one of the austerity measures implemented following the
economic and financial crisis in most of the hardest-hit countries, and were usually part of
the Economic Adjustment Programme agreed between the Eurozone countries in difficulty
and their EU lenders (e.g. CY, EL, ES, IE, IS, IT, PT).

Inequalities in access to healthcare A study of national policies
22
Box 3: Country examples on level of user charges
In Austria, a fee for medicines of €6 per prescription (2018) and a daily allowance for in-patient
care, amounting to between approx. €12 and 19 per day for the first 28 days in hospital per
year, apply.
In Croatia, co-payments range from 10.00 HRK (€1.3) for one visit to a family physician to up
to 2,000 HRK (€266) for hospital treatment, irrespective of length of stay.
In Estonia, there are no user charges in primary care, except for home visits. Co-payment for
specialised outpatient care with a contracted specialist is €5. The reimbursement system for
prescription-only medicines is defined based on the category of the medicine, with a 100%,
90%, 75% or 50% reimbursement rate (in addition to a €2.50 basic co-payment) and is based
on the severity of the disease, the efficacy of the medication and the social status of the patient.
If the cost of the medicines per calendar year is €100-€300, then 50% of the cost is reimbursed
to the person; if the cost exceeds €300, then 90% is reimbursed.
In Ireland, 54% of the population have to pay the full price of GP care but are entitled to public
hospital care, albeit with charges. For example, acute inpatient care requires a co-payment
(€80 per day), capped at €800 per year, as do visits to emergency and outpatient departments
(€100). Co-payments also exist for prescribed medicines, but are capped at €144 per household
per month.
In Germany, co-payments apply to medicines and usually amount to 10% of the cost per
prescription, with a minimum of €5 and a maximum of €10. Inpatients have to pay a maximum
of €10 per day for 28 days per year. The annual sum of co-payments for SHI patients is limited
to 2% of their annual income and to 1% if they are chronically ill.
In Serbia, for the majority of procedures a co-payment is required, unless the patient belongs
to a vulnerable group. The co-payments are in the range of €0.5-€10. Regularly insured persons
may be exempted from user charges, depending on the household’s financial status. For a
single member household, the threshold is an income below 130% of the official minimum wage
(€263 in April 2018) and for a multiple member household the threshold is the minimum wage
per household member (€230)
In Slovenia, user charges amount to 20% of the price of the service for primary care, between
20 and 30% of the price of services in secondary healthcare and up to 90% for non-urgent
medical transport. To cover the high user charges, voluntary complementary health insurance
was introduced and covers 95% of the population (see Section 1.3).
In Sweden, patient fees for primary care normally vary between 150 and 200 SEK (€15 and
20). Fees for specialist care vary between 100 SEK (€10) to at most 400 SEK (€40). Patient
fees for in-patient care range from 40 SEK/night (€4) to 100 SEK/night (€10). There is a
national ceiling for outpatient healthcare costs set at SEK 1,100 (€110) over a 12-month period.
When the ceiling has been reached, the individual pays no further charges for the remainder of
the 12-month period. For out-of-pocket payments of prescribed drugs, a separate ceiling exists.
Up to SEK 1,100 (€110), the patient has to pay the full amount, and the maximum amount
over 12 months is SEK 2,250 (€225).
In Turkey, in case of use of secondary and tertiary health services, a user fee is charged of 6
TL (€1.2) for public provider use and 15 TL (€3.01) for private healthcare.
Source: ESPN country reports
User charges: coverage of specific health services and products
The next paragraphs discuss specific health services and products that are often only
partially covered by the health system.
In the vast majority of countries, co-payments, often substantial, apply for medicines
provided in outpatient care (e.g. AT, BE, BG, CH, DE, DK, EE, EL, ES, FI, FR, HR, HU, IE,
IS, IT, LT, LU, LV, NL, PL, PT, RO, RS, SE, SI, SK, TR, UK). The level of user charges for
medicines may differ depending on the severity of the disease, the efficacy of the
medication and the health and socio-economic situation of the patient (e.g. AT, BE, EE, EL,
FI, HR, HU, NO, PL, PT, SK). User charges for medicines can also be limited depending on

Inequalities in access to healthcare A study of national policies
23
the total annual amount paid (e.g. EE, NL) or an annual cap on user charges may apply,
above which patients are exempted (e.g. AT, CZ, DK, ES, FI, IE, IS, SE, SK). Some
vulnerable groups may be exempted from user charges for pharmaceuticals (see next sub-
section) and some medicines may be fully reimbursed (e.g. BG, FI). Several ESPN experts
emphasise that user charges for medicines are problematically high in their country (e.g.
EE, HR, LT, LV, PL, PT, SI, SK).
Figure 5 presents the public share of spending on pharmaceuticals compared with health
services in 2014. It shows that, in all countries analysed, public funding for health services
is higher than for pharmaceutical products and thus that private spending accounts for a
larger share of payments for medicines.
Figure 5: Public share of spending on pharmaceuticals compared with health services, 2014 (or
nearest year)
Source: OECD/EU (2016), Health at a Glance: Europe 2016; 1Includes medical non-durables; * ESPN countries not included in the dataset: LI,
MK, MT, RS, TR.

Inequalities in access to healthcare A study of national policies
24
In many countries, user charges apply for dental care (e.g. AT, BE, BG, CY, CZ, DE, DK,
EE, ES, FI, FR, HR, HU, IE, LI, LU, SE, SI, TR, UK), while some groups, in particular children,
may be exempted from user charges (e.g. DK, FI, HR, IS, LV, SE, UK) or be eligible for
reduced user charges (e.g. BE, EE). In some countries, outpatient visits to psychologists
(e.g. DK, IS, PT) and outpatient physiotherapy and/or rehabilitation (e.g. BE, CH, DE, DK,
EE, FI, FR, HR, IE, IS, IT, LU, NO, PT, SE, SI, TR) are subject to user charges.
Coverage of medical devices, including prosthetics, orthodontics, glasses, hearing aids and
health services using these devices is usually limited (e.g. AT, BE, BG, CH, CZ, DE, DK, EE,
ES, FR, HU, SI, SK, TR, UK), while for most of these products providers can freely set their
price.
In some countries, the services and products discussed under this heading are fully
excluded from the benefit package. These were discussed in Section 1.2.2.
User charges: protection of vulnerable groups
Some vulnerable groups may be exempted from cost sharing (e.g. AT, BG, CY, ES, FI, HR,
HU, IE, IT, LU, NO, PL, PT, RO, RS, SE, SI, UK and more recently FR), pay lower user
charges (e.g. BE, DK, IS, SK) or qualify for a broader benefit package (e.g. IE). These
protection mechanisms may apply, for instance, to patients on a low income, patients with
chronic conditions or infectious diseases, recipients of certain social benefits, pregnant
women, children and old age pensioners. In Austria, about a quarter of the population and
in Portugal more than half of the population are exempted from cost sharing. Some
vulnerable groups may be exempted from user charges for specific benefits such as
pharmaceuticals (e.g. AT, EL, HU, MT, PT, UK) or dental care (e.g. DK, FI, HR, UK).
In some countries, patients pay up-front for the healthcare and obtain reimbursement from
their health insurer afterwards (e.g. for outpatient care in BE, FR and LU, for the privately
insured in DE and CH). Vulnerable groups may be protected from having to provide up-
front payments through direct payment by the third-party payer to the healthcare provider
(e.g. BE, FR, LU).
For some examples on national policies to protect vulnerable groups, see Box 4.
Box 4: Protecting vulnerable groups from user charges
In Austria, user charges for prescription drugs have been capped at 2% of annual net income
per calendar year for people with low incomes and high drug consumption.
In France, patients with the lowest incomes benefit from almost total coverage of their health
expenses through complementary universal health coverage and thus do not pay any user
charges.
In Greece, certain vulnerable social groups, such as those on a very low income, asylum
seekers, refugees, prisoners, disabled persons, etc. are exempted from any co-payments for
pharmaceuticals.
In Luxembourg, the user charges are generally limited and cannot exceed 2.5% of taxable
income.
In the UK, children, the elderly and members of low-income households are exempt from user
charges on prescription medicines, as are pregnant women and those with children up to one
year and people with certain medical conditions such as cancer, diabetes and epilepsy.
Source: ESPN country reports

Inequalities in access to healthcare A study of national policies
25
Excess fees
In some countries, patients who are entitled to public or contracted outpatient and
inpatient care also have access, on a cost-sharing basis, to health services delivered by
private or non-contracted providers (e.g. AT, BE, EL, FI, FR, IS, PT). In this case, the
providers are free to set their tariffs, with the exception of Portugal, where tariffs are
agreed upon with the Ministry. In France, since recently (2016), providers are no longer
allowed to claim excess fees for vulnerable groups.
Informal payments
There are indications that informal payments (under-the-table payments) made by the
patient or her/his family to physicians are common practice in several countries (e.g. BG,
EL, HU, LT, LV, RO, RS, TR). These payments are made in order to bypass waiting lists and
have access to healthcare of better quality. In Bulgaria, informal payments are estimated
to make up half of the total out-of-pocket payments.
1.3 Voluntary health insurance (VHI)
Voluntary health insurance may supplement, complement or replace publicly financed
coverage and thus can have different functions (Sagan and Thomson 2016). It can cover
a) healthcare benefits not covered by the statutory healthcare basket,
24
for instance dental
treatment (e.g. AT, BG, CH, DE, DK, ES, HU, IE, LU, LV, NL, PT); b) user charges
25
(e.g.
AT, CH, DK, EL, FR, HR, HU, IE, LU, PT, SI); and/or c) a greater choice of providers,
26
for
instance access to private/non-contracted providers, faster access to healthcare or
enhanced amenities, such as admission to a private room in hospital (e.g. AT, BE, CH, CY,
DE, DK, EL, ES, FI, HR, HU, IE, LI, LV, NO, PT, SI, TR).
VHI can be provided by for-profit and not-for-profit actors. Although a large share of the
population is covered by voluntary health insurance in several countries (e.g. AT, BE, FR,
DE, DK, FI, HR, HU, NL), such coverage only represents a small share of total health
expenditure. In some countries the role of VHI is relatively important in ensuring access
to healthcare (e.g. FR, IE, SI). Both in France and Slovenia, complementary health
insurance covering relatively high co-payments is taken out by nearly the whole population.
In Ireland, 45% of the population is mainly covered for healthcare through VHI.
27
In
several countries, the government provides tax advantages to purchase voluntary health
insurance or provides financial support to people on low incomes, enabling them to
purchase complementary VHI (e.g. FR, HR, HU, SI).
In some countries, some groups without compulsory coverage can opt into the social health
insurance system (e.g. AT, BE, EE, PL). This may include, for instance, people whose
income does not reach a certain income threshold. Contribution rates may be relatively
affordable for lower income groups (e.g. AT), but may also be relatively high (e.g. PL).
In some countries, insurers can (and do) refuse to insure people for voluntary health
insurance, due to, for example, health status or age (e.g. CH, DK, EL), whilst in others
(e.g. IE) private health insurers operate on the basis of community rating, open enrolment
and lifetime cover (whereby an insurer may not refuse to renew cover). As an example, in
Denmark, a private non-profit actor, “danmark”, owned by its members, covers 43% of
the whole population. To become a member, the applicant must be younger than 60 and
cannot have any medical condition at the time of entry.
Several countries have well-developed VHI schemes paid for by the employer (occupational
VHI schemes), providing access to private and non-contracted providers free of charge
(e.g. BE, CY, FI, HU, IT, MT, RO) or on a cost-sharing basis (e.g. PT). These schemes thus
24
Commonly referred to as supplementary health insurance.
25
Commonly referred to as complementary health insurance.
26
Commonly referred to as duplicate health insurance.
27
Since the statutory benefit package is very limited for a large share of the population (see Section 1.2.2).

Inequalities in access to healthcare A study of national policies
26
provide faster access, better quality and an increased choice of healthcare providers. In
Finland, 90% of wage-earners are enrolled with various occupational VHI schemes. The
schemes may be supported by public money in different ways. They may receive subsidies
(e.g. FI) and they may be popular as part of the salary package since no taxes or social
contributions are due on these benefits (e.g. BE). Sometimes they cover some or all
categories of public service employees (e.g. CY, FI, PT). In Portugal, state support for the
public service scheme has been drastically reduced. In Bulgaria, some companies have
their own clinics, providing primary care for their workforce. ESPN experts from several
countries mention that the share of the population covered by VHI, in particular by
occupational schemes, is increasing (e.g. BE, CY, EL, ES, FR, IT, MT, NO).
1.4 Availability of health services
While the healthcare benefit package is, in principle, quite broad in most countries,
sufficient services need to be available in sufficient numbers and quality to ensure access
to healthcare in practice. When services are not available in sufficient numbers, patients
who can afford it may seek healthcare in a parallel private sector and pay for it either out
of their own pocket or through voluntary health insurance.
This section provides an overview of the availability of health services in the 35 countries.
Section 1.4.1 discusses the overall supply of healthcare and the gaps in some countries.
Section 1.4.2 zooms in on the availability of health professionals and staff shortages in
some countries. Regional disparities in health services are discussed in Section 1.4.3.
Waiting lists and policies to address waiting times are addressed in Section 1.4.4 while the
role of the private sector is discussed in Section 1.4.5.
1.4.1 The overall supply of healthcare
In many countries, the hospital and healthcare facilities network is considered generally
sufficient (e.g. AT, BE, CH, CZ, DE, HU, IS, LI, LT, LU, MT, SI), although often with some
regional shortcomings (see Section 1.4.3). In others, however, underfunding of the health
system has resulted in underdevelopment of health services as an implicit form of
rationing, as illustrated in Box 5. Limited budgets for health services and quotas as to the
number of services to be performed have led to accumulated deficits of healthcare
institutions, cuts in service provision and underinvestment in infrastructure and health
technologies (e.g. BG, CY, EE, ES, HR, IE, LV, PL, RO, RS). Several ESPN experts stressed
that healthcare for acute health conditions is prioritised over public health, preventive care
and mental health in their country (e.g. BE, BG, EL, ES, HR, HU, IE, LT, RO, TR, UK). The
Romanian country report furthermore stressed that a poor referral system and
questionable effectiveness of the primary health services, have resulted in an increased
burden on hospital medical services, and that the continuity and integration of care
(primary healthcare/ambulatory clinical care/ hospital care) is not sufficiently developed.
In several countries, health services have been reduced due to cost constraints in the wake
of the financial and economic crisis (e.g. EL, ES, IS).

Inequalities in access to healthcare A study of national policies
27
Box 5: Country examples of implicit rationing of healthcare provision
In Bulgaria, there are no official waiting lists, but GPs, who are supposed to act as gatekeepers,
have a quota of referrals to outpatient specialist care per month. They often reach their quota
long before the end of the month which means that remaining cases have to wait until the next
month.
In Estonia, some hospitals use up their contract volumes several months before the end of the
contract period and thus postpone all elective care to the next half-year.
In Germany, it is reported that fixed budgets may lead to “informal rationing”, i.e. not providing
services regarded as medically necessary or (in the outpatient sector) postponing them to the
next quarter or simply discharging patients too early from hospital.
The Vestmanna Islands (south of Iceland, with a population of some 4,500) previously had a
mini-hospital, providing full maternity and birth care services, among other things. This has
now been closed down. Couples expecting a baby thus have to move temporarily to Reykjavík
well before the expected date of birth or rely on emergency services by helicopter, at a high
cost and with the risk of difficult weather conditions.
Source: ESPN country reports
1.4.2 Availability of health professionals
When discussing the supply of health professionals, a distinction should be made between
the overall supply of health professionals and the number of professionals working in the
publicly funded system.
In some countries there are currently no overall severe staff shortages (e.g. AT, BE, BG,
LU), although there may be shortages in specific regions and in specific areas/disciplines.
However, many ESPN experts point to supply shortages of health professionals in their
country (e.g. CY, CZ, HR, HU, LV, PL, RO, SI) and, in particular, reduced numbers of
professionals working in the publicly funded system (e.g. CY, EL, LV, PL, RO). Ageing of
the health workforce is also a cause of concern in many countries (e.g. AT, BE, BG, CZ,
DE, EE, FR, HR, IT, LV, PL). In some countries, shortages are particularly acute in the case
of nurses (e.g. BG, EE, EL, HR, HU, LV, SK) and general practitioners (e.g. BE, CY, DE, DK,
EL, FR, HR, HU, PL, PT, RO, SI).
There are mainly two reasons for such shortages: a) reduced numbers of professionals
entering the labour market, for instance due to quotas limiting access to university medical
education (e.g. IT, PL); and b) medical professionals leaving to work in more attractive
areas, in particular urban centres, to work abroad (e.g. BG, EE, HR, IE, LV, PL, RO, RS) or
to work in the private or non-contracted sector (see below). Factors which make working
in the public system less attractive include poor wages and working conditions (e.g. BG,
CY, EE, IE, LV, PL, RO, RS).
Understaffing of health institutions in the publicly funded system may also be the result of
budget cuts, in particular in the wake of the financial crisis. In most of the countries heavily
hit by the crisis, austerity measures included important staff reductions, freezes on hiring,
limits placed on the number of contracts with health professionals in the publicly funded
institutions and/or reduced wages (e.g. CY, EL, ES, IE, IT). For instance, in Greece, over
the period 2010-2015, a decrease of 33.3% has been observed in the number of medical
personnel employed in the health centres.
1.4.3 Regional disparities in health services
Substantial inequalities in the supply of health services between regions (e.g. CH, EL, ES,
IT, LV, PL, PT, SI, TR, UK) and across urban and rural areas (e.g. BG, CH, CZ, EL, FI, FR,
HR, HU, LT, LV, PT, RO, RS, SI, TR) are frequently reported in the ESPN country reports.
Shortages of medical practitioners are particularly acute in rural areas (e.g. AT, BE, CH,
CZ, DE, EL, FR, HR, HU, LT, LV, NL, RS, SI, SK, TR). For instance, in France, 23% of the

Inequalities in access to healthcare A study of national policies
28
mainland population experience difficulties finding a general practitioner closer than a
thirty-minute drive from their home. However, in some countries shortages of medical
professionals have also been reported in disadvantaged urban areas (e.g. DE, FR). Several
ESPN experts furthermore emphasise that the shortages of medical doctors in
disadvantaged regions have become more serious over recent years or they foresee
important human resources challenges in the near future (e.g. BE, BG, CZ, DE), while in
some urban agglomerations there may be oversupply (e.g. DE). The situation is a particular
cause of concern in relation to general practitioners and primary care services (e.g. BE,
DE, DK, EL, FR, HR, HU, PT, RO, SI). Some ESPN experts also point to important differences
in quality of healthcare between regions (e.g. LV, NO, UK). This may, among other things,
be related to the lack of sufficient experience of specialists and to the low numbers of
patients to be treated in specific medical disciplines. Some countries have taken measures
to incentivise physicians to work in rural areas, in particular for primary care services (e.g.
BE, FR, LT, PT).
1.4.4 Waiting times
Health systems where healthcare is, as a general principle, free at the point of use, more
often apply supply restrictions, as a key instrument to contain costs. The number of
healthcare providers available is thus more strictly planned and free choice of healthcare
provider is limited (Siciliani et al., 2013). Supply restrictions may imply waiting times, used
as a tool for priority setting and supply management. Waiting lists may, however, become
a form of implicit rationing if the health system is unable to provide healthcare within an
acceptable time to patients, taking into account their health condition.
While in some countries waiting times do not seem to be a major problem (e.g. BE, LI,
LU), they are an issue of considerable concern in a large majority of European countries
(e.g. AT, CY, CZ, DE, DK, EE, EL, ES, FI, FR, HR, HU, IE, IS, IT, LT, LV, MT, NL, NO, PL,
PT, RS, SE, SI, SK, TR, UK) and are a focus of public debate. Underfunding of the health
system and staff shortages in the publicly funded sector are often mentioned by ESPN
experts as the reason for problematically long waiting lists (e.g. CY, EE, EL, ES, HR, IS,
LV, PL, RS, SI, TR, UK). In some countries, additional funding has resulted in a reduction
in the average waiting times in general, or for specific treatments (e.g. HU, IS, LV, MT, NL,
NO, PT) while in others they are steadily increasing (e.g. ES, PL, RS, SI, UK).
In some countries, waiting lists are an issue for the entire health system, while in others
they only exist for access to certain types of care. For some examples, see Box 6. Waiting
times may also differ between different regions (e.g. ES, FR, HU, IS, IT, SE).
In some countries, official waiting lists for specific treatments (e.g. AT, DK, MT, PT, SI) or
official criteria for priority setting (e.g. NO) exist, while in others there is a complete lack
of transparency on priority setting or no monitoring of waiting times (e.g. BE, CY, CZ, FR,
HR, LU, LV,
28
PL, RO). But even in some countries with official waiting lists, these lists can
be, and are in practice, bypassed, for instance by arguing that a case is urgent (e.g. AT,
MT).
Many countries have established maximum waiting time guarantees or targets (e.g. DE,
DK, EE, FI, IS, NL, NO, PT, SE, SI, UK). Patients waiting longer than the maximum waiting
time in principle obtain more freedom to choose a healthcare provider, for instance a
private/non-contracted provider or a provider outside their health region. For some
examples, see Box 6.
28
In Latvia, since mid-July 2018, waiting times in the various medical institutions are publicly accessible online.

Inequalities in access to healthcare A study of national policies
29
Box 6: Country examples on waiting times and waiting time guarantees
In Austria, there are waiting lists for some specific medical examinations or specific types of
surgery in public hospitals.
In Belgium there are no waiting times for GPs, but patients must wait some time for certain
specialist doctors (in particular for mental healthcare).
In Cyprus, the long waiting lists and the lack of transparency are highlighted as the most serious
problem affecting the system at present, responsible for widening inequalities in access to
healthcare. During the crisis years, when even more people turned to the public sector, the
problem worsened further and waiting lists grew even more. Knee and hip replacements are
being delayed by 30 months; cataract surgeries by 15 months.
In Estonia, the accessibility of primary care is very good, while in outpatient specialised care,
half of patients cannot access services within the specified maximum waiting time.
In Germany, associations of statutory health insurance physicians (Kassenärztliche
Vereinigungen) are obliged to establish appointment service points, where patients can request
a specialist appointment within an appropriate timeframe. However, it was reported that
appointment service centres were not always available in practice.
In Ireland in 2015, 10% of patients had to wait more than a year to get first access to out-
patient services in hospitals.
In Latvia, the waiting time for out-patient health services fluctuates between 20 days and 680
days.
In Portugal, in 2016 approximately 28% of medical appointments took place beyond the
maximum guaranteed response time. Compliance with the maximum waiting times improved
substantially between 2010 and 2016, in particular for cases identified as very high priority.
In Sweden, despite the guaranteed maximum waiting time, around 25% of patients in specialist
care presently have waiting times exceeding 90 days.
Source: ESPN country reports
1.4.5 The role of private sector health providers and healthcare fully paid
out-of-pocket
In several countries a large private sector, fully paid out-of-pocket or through voluntary
health insurance, co-exists with the publicly covered sector (e.g. CY, EL, FI, HU, MT, PL,
PT, RS, RO). In other countries there is an important segment of physicians providing
healthcare outside the contracting system and who are thus free to set their tariffs, while
qualifying for partial reimbursement from the public purse (e.g. AT, BE, EL, FI, FR, IS, PT).
In most countries, doctors, in particular specialists, can work in the public or contracted
sector and also have a private practice (e.g. BE, DE, EE, ES, FI, HR, LT, LV, MT, PL, RO,
SI). Some ESPN experts highlight a growing private for-profit sector, funded by the public
system (e.g. AT, FI, SE).
The private sector is mainly used by patients who want to avoid long waiting times, by
people who can afford it (e.g. AT, CY, EE, ES, FI, HU, IE, LT, MT, PL, PT, RS, SI). According
to many ESPN country experts, patients can bypass waiting times in the public sector if
they (first) consult the specialist privately and therefore pay additional fees.
Voluntary health insurance plays a crucial role in the development of the private sector in
many countries, in particular when it is used to circumvent the waiting lists (e.g. DK, ES,
FI, LV, PT, SE). Similarly, in countries where voluntary health insurance is used to cover
user charges, excess fees, or private rooms in hospital, VHI appears to encourage the
development of a sector of non-contracted providers (e.g. BE, FR).
In some countries, doctors are leaving the public sector to work in the private sector (e.g.
CY, LV). Several ESPN experts from countries where non-contracted physicians (who are
free to set their prices) qualify for partial reimbursement from the public purse, flag that

Inequalities in access to healthcare A study of national policies
30
the number of providers leaving the contracting system is increasing (e.g. AT, DE, FR).
The interaction between the public/contracted sector and the private sector is illustrated
in Box 7.
Box 7: Interaction between physicians working in the public/
contracted sector and in the private sector
In Austria, the number of non-contracted physicians is steadily increasing. As the fees of non-
contracted GPs and specialists are largely unregulated and only partly covered by social health
insurance, access to ambulatory healthcare is increasingly based on ability to pay rather than
medical need.
In France, there has been a steep increase in practices charging excess fees. The proportion of
general practitioners authorised to charge excess fees rose from 39.2% in 2006 to 44.3% in
2015. 84% of gynaecologists and 69% of ophthalmologists are authorised to charge extra fees.
These physicians are highly concentrated in some regions.
In Germany, social health insurance (SHI) patients often face significantly longer waiting times
than members of the private health insurance (PHI). Since general practitioners and outpatient
specialists are allowed to charge PHI patients considerably higher fees, privately insured
patients can be seen as priority consumers. The current SHI/PHI-divide is considered a crucial
reason for the disparities in the geographical distribution of doctors.
In Iceland, private providers have pushed for more freedom of access to public funding of
services, in light of longer waiting periods, such as for hip or knee replacements. It is expected
that the transposition of the EU Directive29 allowing patients on waiting lists to seek operations
in other EEA countries will further increase pressure for increased private provision in some of
the areas most affected by excessively long waiting lists.
In Ireland, physicians can treat patients on a private basis in public hospitals. A block grant
system used to reimburse hospitals for public patients, in contrast to per diem charges for
private patients, creates an incentive to treat fewer public patients. This represents a
subsidisation of private health services by public resources.
In Latvia, the disparity between the state-established tariffs and the actual costs of services
results in a situation whereby health service providers refuse to conclude agreements on
provision of state-paid health services and provide only paid services.
In Luxembourg, all medical professionals must apply the tariffs agreed with the national health
insurance institute. There is thus no non-contracted sector in Luxembourg.
In Malta, although strictly speaking any patient can have access to in-patient treatment through
the public primary healthcare system, people feel the need to accelerate their access to
healthcare by first visiting the same specialists manning the public sector privately.
Source: ESPN country reports
29
European Parliament and Council of the EU (2011).

Inequalities in access to healthcare A study of national policies
31
2 Tackling challenges in inequalities in access to healthcare
This section first analyses the existing and newly emerging inequalities in effective access
to healthcare, provides insights into the reasons behind them (Section 2.1) and discusses
recent reforms (Section 2.2). Many strengths and weaknesses of health systems in
ensuring equal access to healthcare are country-specific. There are, however, also common
features across countries. Although it is not possible to determine a causal relationship
between effective access to healthcare and system characteristics, we will, where possible,
highlight system features as described in Section 1, to provide potential explanations for
the observed inequalities in access to healthcare. Section 2.1.1 provides a general picture
of inequalities in access to healthcare. We then discuss inequalities in access to healthcare
between population groups (Section 2.1.2). Section 2.1.3 then looks at the different
reasons for unmet needs, linking them, where possible, to system characteristics. Section
2.1.4 discusses some cross-cutting findings on weaknesses and strengths of health
systems with regard to access. Finally, Section 2.2 reviews recent and planned reforms
and on-going debates.
2.1 Effective access to healthcare: explaining unmet needs
2.1.1 Inequalities in effective access to healthcare: the general picture
As described in Section 1, in most of the 35 countries under scrutiny, and in particular the
EU Member States, the majority of the population is covered under the statutory health
system for a broad range of services (see Figure 4). However, in all countries there are
specific – sometimes small – population groups falling through the safety net of the
statutory health system, and in some countries gaps in coverage are substantial (see
Section 1.2.1). Furthermore, Section 1 has also shown that in some countries there are
significant issues due to the funding, the design and the functioning of the system which
may lead to unmet needs for healthcare. Thus, even if people are statutorily covered by
the health system, they may have significant unmet needs due to cost, waiting times and
travelling distance. In order to capture these unmet needs, we use the EU indicator on
self-reported unmet needs for medical examination. Although indicators on self-reported
unmet needs have their limitations when it comes to objectively capturing health needs,
since they measure people’s subjective perception of their needs, they are the best
available proxy to measure unmet medical needs (see also Section 3)
30
.
Figure 6 shows the overall self-reported unmet needs for medical care due to cost, travel
distance and waiting time in 2008 and 2016. While only 2.5% of the EU population reports
unmet needs for medical examination, there are significant differences between countries.
Estonia, Greece and Latvia score highest on this indicator, with figures of 15.3%, 13.1%
and 8.2% respectively, while Austria (0.2%), the Netherlands (0.2%) and Germany (0.3%)
perform well in this respect. Compared to eight years ago (2008), the situation has
improved in several countries. The most significant fall in unmet needs is observed in
Bulgaria, with a drastic decrease from 15.3% to 2.8%; Romania (from 11.1% to 6.5%);
and Germany (from 2.2% to 0.3%).
30
As argued in the opinion on Access to health services in the European Union, produced by the Expert panel on effective ways of investing
in health, “Health need has been defined as the ability to benefit from healthcare. This implies that there is information on the presence of
a health problem and the existence of a corresponding treatment. It also implies that there is a defined threshold above which treatment is
appropriate. In practice, this type of information is not readily available. (…) Given the challenges of undertaking such studies on a large
scale, social surveys typically use questions that seek to elicit self-reported unmet need, with a focus on quantifying instances in which
people are not able to obtain the health (or dental) services they need because they face barriers to access. This is achieved by asking
respondents whether they were unable to obtain care or treatment when they believed it to be medically necessary.” (EXPH 2016).

Inequalities in access to healthcare A study of national policies
32
Figure 6: Self-reported unmet needs for medical examination due to cost, distance and waiting
time
Source: Eurostat [hlth_silc_08]; * ESPN countries not included in the dataset: LI; **No data for 2008 for the following ESPN countries: HR,
MK, RS; *** Data for IS and TR refer to 2015, no data available for 2016.
Importantly, the 2008 economic and social crisis had a significant effect on access to care.
There was a substantial increase of the EU average during this period (2009-2014) —
namely from 3.0% (2009) to 3.4% (2012), with the highest value in 2014 (3.6%). This
may be explained by the austerity policies in many countries, loss of entitlement for some
groups and, at the same time, an increasing need for healthcare. Since then, a gradual
recovery has taken place, and unmet need in 2016, at 2.5%, is, for the first time, below
the level of 2008. Furthermore, and more importantly, there were significant variations
between Member States. There have been five countries with significant increases in unmet
needs, especially during the crisis years (2011-2014): Belgium, Estonia, Greece, Iceland
and Finland. In Belgium, Estonia and Finland in particular, there is still an upward trend
(2016) (see Figure A1 in Annex 1). In other countries (e.g. BG, CY, HR, HU, LT, LU, LV,
MK, RO, RS, TR), there was a slight increase between 2011-2014 and a steady decrease
since then (see Figure A2 in Annex 1).
When looking more closely at the reasons for unmet needs, cost is definitely the most
important factor, in most countries, impeding effective access to healthcare. The most
extreme case is Greece, with 12% of self-reported unmet needs for this reason alone. It is
followed by Turkey with 6.2% and by Romania and Latvia, both with 5.3% (see Figure 7).
The second most significant factor impeding effective access is the issue of waiting lists —
with the highest score 13.5% in Estonia, followed by Finland (4%). Finally, there is the
factor of travelling time, which is far less important: Estonia has the highest score here:
0.7%.
These inequalities in effective access to healthcare can be explained by two interlinked
groups of factors, which we discuss below: a) those related to characteristics of population
groups, such as income, activity status, age, gender, ethnicity, disability status and health
literacy; and b) those involving the health system design, including costs, waiting lists and
territorial disparities. Moreover, the characteristics of the health system may address the
needs of some population groups more comprehensively than others.

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33
Figure 7: Self-reported unmet needs for medical examination by main reasons (2016)
Source: Eurostat [hlth_silc_08]; * ESPN countries not included in the dataset: LI; ** Data for IS and TR refer to 2015, no data available for
2016.
2.1.2 Explaining unequal access: population groups
Inequalities based on income
Unsurprisingly, several ESPN experts point to income as a key factor explaining inequalities
in access to healthcare: the lower the income, the more unmet needs (e.g. BE, BG, EE, EL,
ES, FR, HU, IE, IS, IT, LV, RO, RS, SE). Indeed, as Figure 8 shows, some countries display
substantial differences in self-reported unmet needs for medical examination due to cost
between the lowest and highest income quintiles (BE, EE, EL, LV, RO, RS). The most
striking example is Greece, where those in the lowest income quintile report 34.3% of
unmet needs due to cost, with only 0.4% in the highest. Only a few countries – namely
those with the lowest scores on unmet needs due to cost – report barely any difference
between income groups (AT, CZ, DE, DK, FI, NL, SI, UK).
Figure 8: Self-reported unmet needs for medical examination due to cost by income quintile (2016)
Source: Eurostat [hlth_silc_08]; * ESPN countries not included in the dataset: LI; ** ESPN countries with no data for 2016: IS, TR.
0
5
10
15
20
25
30
35
EL
LV
IT
RO
BE
BG
PL
PT
EU28
EE
FR
IE
HU
HR
LT
CY
SK
MT
SE
LU
CZ
DE
AT
ES
SI
DK
NL
UK
FI
RS
MK
CH
NO
First quintile Third quintile Fifth quintile
%

Inequalities in access to healthcare A study of national policies
34
In some countries, the economic crisis had a significant impact on access to healthcare for
the lowest income earners. The Greek ESPN experts report that unmet needs for medical
examination increased dramatically from 2010 to 2016: by 26.2 percentage points (p.p.),
i.e. from 9% in 2010 to 35.2% in 2016 for the lowest income quintile. This substantial
increase is mainly due to a 26.6 p.p. increase in the number of people in the first quintile
who reported unmet medical needs due to cost (i.e. from 7.7% in 2010 to 34.3% in 2016).
Similarly, the Belgian ESPN experts report an increase in social inequalities in access to
healthcare during the crisis period: between 2011 and 2016, unmet needs in the lowest
income quintile increased from 4.2% to 7.7%.
The reasons for inequalities in unmet needs due to cost between income groups are
complex, and several factors should be considered carefully. The countries topping the
charts for unmet needs due to cost, are those where out-of-pocket payments as a share
of total health expenditure are highest (e.g. BG 46%, LV 39%, EL 35%, IT 22%, RO 20%,
see Figure 1). Furthermore, among the countries with the highest unmet needs, in
particular in the first income quintile, are most of the countries for which ESPN experts
stressed that the system is underfunded (e.g. BG, EL, IE, IT, LV, PL, RO, RS, see Section
1.1).
Ireland is a specific case, since there the middle-income groups also have substantial
unmet needs. As mentioned in Section 1.2.2, over half of the population covered, in
particular those on higher incomes, are entitled only to public hospital care. According to
the Irish country report, there is a significant difference in the use of GP and prescription
services between those with and without coverage for primary healthcare. In particular,
people on a (lower) middle income may have difficulty in bearing the costs of healthcare
and may not be able to afford private health insurance.
The situation concerning unmet needs due to cost is even more acute with regard to dental
care (3.6%, compared to 2.5% for medical examination): seven EU countries report unmet
needs significantly higher than 5% for dental care (EE, EL, ES, IT, LV, PT, R0), as can be
seen in Figure 9.
Figure 9: Self-reported unmet needs for dental examination due to cost (2016)
Source: Eurostat [hlth_silc_09]; * ESPN countries not included in the dataset: LI; ** ESPN countries with no data for 2016: IS, TR.
Importantly, for dental care there is a clear gap between the lowest and the highest income
quintile for significantly more countries than is the case for medical examinations. The
middle-income quintile is also significantly affected by self-reported unmet needs for dental
examination in several countries, compared to unmet needs for medical examination (see
Figure 10). This can be partly explained by the fact that in several countries dental care
services are included only partially, or not at all, in the healthcare basket (see Section
1.2.2) and people have to provide high out-of-pocket payments for these treatments.

Inequalities in access to healthcare A study of national policies
35
Voluntary insurance schemes may be unaffordable for those on a low income (see Section
1.3).
Clearly, countries with low coverage for dental care (see Section 1.2.3) perform
substantially worse in access to dental care, in particular for low income groups. It should
be noted that this includes some of the countries with an excellent performance for access
to medical examinations (e.g. DK, ES, IS, NO, SE).
Figure 10: Self-reported unmet needs for dental examination due to cost, per income quintile
(2016)
Source: Eurostat [hlth_silc_09]; * ESPN countries not included in the dataset: LI; ** ESPN countries with no data for 2016: IS, TR.
Inequalities based on activity status
Activity status may also play an important role in explaining problematic access to medical
care in some countries. Most countries show significant differences between activity
statuses. The unemployed in particular (and to a lesser extent pensioners) may encounter
considerable difficulties in accessing healthcare (see Figure 11). In Greece 21.5%, in Latvia
16.7% and Estonia 15.9% of the unemployed report unmet needs for medical examination.
As discussed in Section 2.1.1, these are countries where unmet needs are important in
general. In Greece most of the unemployed have only been covered for healthcare since
2016 (see Box 13 below) and this may not yet be visible in the 2016 data.
Figure 11: Self-reported unmet needs for medical examination according to activity status (2016)
Source: Eurostat [hlth_silc_13]; * ESPN countries not included in the dataset: LI; ** ESPN countries with no data for 2016: IS, TR.

Inequalities in access to healthcare A study of national policies
36
But even in countries where the percentage of unmet needs among the entire population
is below the EU average, the unemployed may have a significant level of unmet needs for
medical care (e.g. BE, FR, FI, HU, NO). In countries with well-developed (often
occupational) VHI schemes, providing access to private and non-contracted providers free
of charge (e.g. BE, CY, FI, HU, IT, LV, MT, RO), inequalities in self-reported unmet needs
for medical examination according to activity status appear to be important (see Box 8 for
some examples).
Box 8: Country examples on the link between occupational health insurance
coverage and inequalities in access to healthcare
According to the Finnish ESPN expert, the main factor behind the observed inequality in access
to healthcare is the fragmented health coverage in the country. Those with low financial
resources and in difficult labour market positions mainly depend on the municipal healthcare,
where they may face long waiting times. For most employed people, rapid and free access to
primary healthcare is guaranteed through occupational healthcare. In addition, those on a
higher income may top up the healthcare provided by the two other sectors with private
healthcare, and thus trade off high co-payments for easy access to healthcare.
In France, 95% of the population has taken out complementary health insurance to cover
relatively high co-payments. Yet, a noteworthy 5% of the French population do not have
complementary coverage. This is mainly true for the unemployed and retired people with low
pensions.
According to the Italian ESPN experts, the growth in occupational health insurance coverage
(created by social partner agreements or companies’ own decisions) may increase inequalities
in access to healthcare. Occupational welfare generosity depends strongly on companies’
characteristics (size, productivity level, etc.). The expansion of occupational healthcare funds
is explained by various factors: these include the cuts to the NHS expenditure during the last
decade, the relatively low level of public expenditure compared to other Western European
countries and the high share of out-of-pocket expenditure.
Source: ESPN country reports
Pensioners are among the most vulnerable groups, and their access to healthcare may be
significantly impeded, mostly in Central and Eastern European countries (BG, EE, HR, LV,
MK, PL, PL, RO, SK,), but also in Greece, Ireland and, to some extent, Italy. Estonia and
Romania top the charts, with 19.3% and 14.4% of pensioners declaring unmet needs for
medical examination. Strikingly, apart from Cyprus, this includes all the countries where
more than 5% of the population were not covered for healthcare in 2014 (e.g. BG, EE, EL,
PL, RO, SK) (see Figure 4). In some of these countries, pensioners have to pay mandatory
health insurance contributions (e.g. EL, MK, PL) (see Section 1.2.1), but may in practice
be unable to pay.
Inequalities based on gender and household type
Gender is also a factor having an impact on unmet needs for a medical examination:
women are (far) more disadvantaged than men in the majority of the 35 countries under
scrutiny (see Figure 12). In some countries, the gender gap in unmet needs is particularly
striking: around 5 p.p. in Estonia, 4 p.p. in Romania, 3 p.p. in Greece.

Inequalities in access to healthcare A study of national policies
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Figure 12: Self-reported unmet needs for medical examination by gender, due to cost, distance and
waiting time, 2016
Source: Eurostat [hlth_silc_08]; * ESPN countries not included in the dataset: LI; ** ESPN countries with no data for 2016: IS, TR.
.
Older women can be particularly affected by unmet needs for medical examination. For
instance, the Slovenian ESPN experts flag the results of a nation-wide project “Better
Health and Reducing Health inequalities — Together for Health”, the aim of which was to
identify vulnerable groups. Women aged 50+ were identified by the project as the most
vulnerable group. Typically, this situation has been associated with unemployment, socio-
economic vulnerability and mental health problems.
Single person households are another vulnerable group with regard to access to healthcare
(e.g. BE, CH, FR). A study carried out in France demonstrates that single-parent families
and people living on their own have the greatest unmet needs for medical examination. In
Latvia, when assessing inequalities in access, one of the groups that should be mentioned
is the elderly and pensioners, in particular single pensioners, the majority of whom are
women.
As Figure 13 shows, single persons with children, and in particular single females, are
among the most vulnerable categories with regard to their assessment of the ease of
access to and affordability of health services.

Inequalities in access to healthcare A study of national policies
38
Figure 13: Persons using health services by household type and level of difficulty in affording
health services (EU28, 2016)
Source: Eurostat [ilc_ats12].
Particularly vulnerable groups in relation to access: homeless people, migrants
and ethnic minorities
ESPN experts also identified homeless persons (and other marginalised groups such as
alcohol and drug addicts) as a particularly vulnerable category with regard to effective
access to healthcare (e.g. AT, BE, HU, LU, PT, SI). Often, these people are not covered by
the health system, particularly if they are not entitled to cash social protection benefits
(see Section 1.2.1). Many other factors may explain their lack of effective access to
healthcare, including their lack of a registered address, lack of information regarding their
rights and the services available to them as well as poor health literacy. These people have
a significantly worse health status and more often make use of hospital emergency
services. Interestingly, in Hungary a specific indicator has been developed to monitor the
access of homeless people to healthcare. The indicator is, however, biased as it only
considers the fraction of the homeless population registered as homeless with the health
insurance. The results are quite telling: homeless persons use emergency care services
three times more than the general population and are hospitalised as emergency in-
patients significantly more frequently.
Several ESPN reports, mostly from Central and Eastern Europe (e.g. BG, HU, HR, MK, RS,
SI, SK), stress that Roma populations are among the most vulnerable with regard to access
to healthcare, as can be seen in Box 9.

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39
Box 9: Access to healthcare for Roma: policy challenges and good practices
In Hungary, among the Roma unmet medical need was 2.2 times higher than among the non-
Roma (2015).
In the FYR (Former Yugoslav Republic) of Macedonia, a 2016 UNICEF survey on barriers to
access to health insurance among Roma found that 9% of the surveyed households did not
have any form of health insurance. Nearly half (45.6%) of all uninsured people cited lack of
identification documents as the most common reason for the lack of health insurance, in
addition to poor health literacy and scarcity of information. 26% of the surveyed Roma women
declared that they do not need a family doctor, while another 12% say they do not know how
to choose their doctor. The location of their health centre and doctor was an additional factor.
In Romania, about two fifths (42%) of Roma do not seek healthcare when they actually need
it (vis-à-vis 25% of their non-Roma neighbours). Poverty is the most commonly reported
reason for not consulting a doctor when needed — a consultation would be “too expensive”
(84%), with “not having insurance” being the next most frequently cited reason (5%). The lack
of identity documents for registration, coupled with the reluctance to visit healthcare facilities
due to practitioners’ attitudes and uncertainty about what is to be paid, are also major concerns
among Roma.
In Slovakia, almost 58% of municipalities with Roma settlements do not have a general
practitioner (GP), 69% of municipalities are without paediatric services and 68% without dental
provision. There have been documented examples of ethnic segregation in hospitals’
gynaecological wards (separated and overcrowded rooms for Roma women), lower quality of
services, longer waiting hours and degrading and violent behaviour of hospital staff.
Measures for the improvement of Roma access to healthcare
In the FYR of Macedonia, local and national interventions have been implemented in recent
years, aimed at increasing Roma healthcare coverage, with significant EU funding. Several
piloted models are considered successful and ready for roll-out as cost-effective interventions
(e.g. UNICEF, Norway/EEA grants, ESIF funded projects). Community nurses may provide basic
healthcare when needed, but usually focus on health promotion and education, whilst Roma
health mediators may serve as facilitators between Roma communities and healthcare
providers. A law regulating the status of community nurses was passed in 2017 and the
government is attempting to give new momentum to a comprehensive network of Roma health
mediators. Yet both of these initiatives are still in their infancy. The Roma Health Mediators
(RHM) programme, which was introduced in 2012, is reported to have increased the number
of Roma who have access to the health system.
The Portuguese “Programme for municipal Roma mediators” has been acknowledged as good
practice by the Council of Europe.
In Slovakia, as part of the Strategy for Integration of Roma up to 2020, a specific programme
“Healthy Communities” was launched in 2013 to address poor health conditions and insufficient
access to healthcare among Roma marginalised communities. Within the project (more than
200) health assistants worked directly in marginalised Roma communities, focusing on health
education, health assistance, and increasing trust in the health system. As a follow-up to this
programme, a new project called “Health regions” – funded by the ESF and run by the Ministry
of Health – was launched in 2016, with the aim of further increasing access to healthcare,
improving health literacy and promoting health-related behaviour.
Source: ESPN country reports
In the context of the inflow of migrants witnessed over the past decade in Europe, access
to healthcare for migrants, particularly for asylum seekers, refugees and undocumented
migrants, is becoming an acute issue. These groups have been reported to be in a
particularly vulnerable situation in several countries with regard to access to healthcare.
As Section 1.2.1 highlights, asylum seekers and undocumented migrants have restricted
formal access to healthcare in most countries under scrutiny: access for undocumented
migrants is typically limited to urgent medical care and preventive care. However, even
where basic formal access exists, effective access may be hindered by several (cultural
and other) hurdles (see Box 10).

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40
Box 10: Access to healthcare for asylum seekers and undocumented migrants:
policy challenges and good practices
In Belgium, entitlement to “emergency” and “necessary” healthcare can often not be accessed
in practice, because of poor awareness of these rights, fear of being reported to immigration
authorities and complex administrative procedures.
In Denmark, whereas all registered residents are entitled to a comprehensive package of health
services, this is not the case for non-residents, who only receive emergency healthcare.
Undocumented migrants normally receive healthcare provided by a voluntary, privately funded
initiative of the Danish doctors, supported by the Danish Red Cross and Danish Refugee Aid.
In Germany, access for asylum seekers is restricted to treatment of acute diseases and pain in
the first 15 months of their stay in the country. It has been established that the gap between
need for and entitlement to healthcare in many cases is high, in particular as asylum seekers
often suffer from not only physical but also from psychological disorders.
In Malta, asylum seekers, persons with international protection as well as certain third country
nationals are at times unable to access information about health services targeting their specific
needs. They may also encounter language problems due to a lack of sufficient cultural
mediators and lack of health professionals trained in dealing with these groups. A Primary
Health Care Migrant Unit is available to help migrants to access the health system.
In Spain, the exclusion of undocumented migrants from accessing the public health system was
one of the most direct (and controversial) measures adopted in the heat of the financial crisis.
Several national (Ombudsman, Tribunal de Cuentas, Constitutional Court) and international
institutions (Council of Europe, UN Special Rapporteur on extreme poverty and human rights)
made clear statements criticizing the exclusion of this vulnerable group from the public health
system and pointed to the potential public health risks of not adequately treating patients.
However, since regional health authorities have a large degree of discretion in Spain, the
exclusion of this group from healthcare was implemented in a rather limited way.
Source: ESPN country reports
Access to health promotion and disease prevention for vulnerable groups
Inequalities in access to preventive services and health promotion have been highlighted
by many ESPN experts, as Box 11 illustrates.
Box 11: Inequalities in access to health promotion and preventive services
In Austria, low income groups less frequently attend preventive cancer examinations and
display lower rates of vaccination.
In Belgium, socio-economic inequalities persist in the use of preventive care such as breast
cancer screening, vaccinations and preventive dental care.
In France it was reported that in particular women from disadvantaged groups are less likely
to take up preventive care, as illustrated by disparities in access to breast cancer screening.
In Germany, inequalities in the use of secondary prevention (early detection of diseases,
particularly cancer, and detection of risk factors for cardiovascular diseases and diabetes) have
been reported. Access rates to secondary protection for the unemployed, the low-paid, poorly
educated and ethnic minorities are clearly below average. The reasons for this phenomenon
are multifaceted, including a lack of knowledge about health.
In Hungary, there are substantial regional differences in the availability and participation rate
of screenings.
In Italy, differences in secondary prevention are reported in the three main Italian macro-
regions.

Inequalities in access to healthcare A study of national policies
41
In Romania, access to health promotion and disease prevention is unequal, based on available
funds. Most affected by the uneven access to health services are children under 5 years and
teenagers, who are barely covered by either preventive care or screening.
In the UK it was found that wealthier patients consume more preventive care (for example,
screening and vaccination services).
Source: ESPN country reports
2.1.3 Explaining inequalities in effective access: considering health system
design
This section discusses the three main reasons for self-reported unmet needs for healthcare
that can plausibly be related to system characteristics.
Among the major issues related to health system design are unmet needs due to waiting
lists, geographical disparities in healthcare provision and costs. As Section 1.4 highlighted,
there are significant shortcomings in the provision of health services and health
professionals in some countries. Costs of healthcare have already partially been discussed
in Section 2.1.2, since they are strongly related to access issues for the lower income
groups. In this section we will further expand on the role of out-of-pocket payments as a
barrier for access to healthcare. First, we will discuss waiting times, next, distance to
healthcare and finally, the cost of healthcare and out-of-pocket payments.
Waiting times
Waiting lists are by far the most important reason for unmet needs for medical examination
in some countries (e.g. CZ, DK, EE, ES, FI, LT, NL, NO, PL, SE, SI, SK, UK), compared to
the two other factors explaining unmet needs (cost and travelling time) (see Figure 5). As
mentioned already, Estonia has the highest share of unmet needs due to waiting lists
(13.5%), followed by Finland (4%) and Poland (3.9%). There has not been a significant
increase over the past ten years except for in Finland and Estonia, where unmet needs due
to waiting lists increased from 0.3% to 4% and from 5.4% to 13.5% respectively. The
most positive development has been in Bulgaria, where the percentage of unmet needs
due to waiting lists has been reduced from 2.8% to 0.2% (see Figure 14).
Figure 14: Self-reported unmet needs for medical examination due to waiting lists (2008-2016)
Source: Eurostat [hlth_silc_08]; * ESPN countries not included in the dataset: LI; ** No data for 2008: HR, MK, RS; *** Data for IS and TR
refer to 2015, no data available for 2016.

Inequalities in access to healthcare A study of national policies
42
In some countries, those in the lowest income quintile are also particularly disadvantaged
compared to the highest earners with regard to waiting times (e.g. EE, FI, IE, LV; see
Figure 15). Finland tops the chart with a gap of 3 p.p. (5.1% for the first quintile compared
to 2% for the fifth).
Figure 15: Self-reported unmet needs for medical examination due to waiting times by income
quintile (2016)
Source: Eurostat [hlth_silc_08]; * ESPN countries not included in the dataset: LI; ** ESPN countries with no data for 2016: IS, TR.
ESPN experts from countries with the most acute (subjective) unmet needs due to waiting
times have reported (objective) long waiting lists (See Section 1.4.4). Underfunding of the
health system and staff shortages in the publicly funded sector have been often mentioned
by ESPN experts as the reason for problematically long waiting lists (see Section 1.4.1).
This was also the case for Estonia, the country with the highest and increasing unmet
needs due to waiting times. The Estonian ESPN country experts pointed out that, contrary
to most other SHI systems, the state barely contributes to the system for non-contributing
individuals (e.g. children, the unemployed, pensioners), who make up more than half of
those insured. This results in a lack of funding of health services, staff shortages and thus
long waiting times. For instance, some hospitals use up their contract volumes several
months before the end of the contract period and thus postpone all elective care to the
next half-year.
In Finland, as highlighted in Section 1.2.1, the main reason for unmet needs is the
fragmented health coverage in the country, with long waiting times in the municipality
system. The hardest-hit groups are the low-income earners, since for most employees,
rapid and free access to outpatient care is guaranteed through occupational health
insurance coverage, and this system is often more effective than the public system. For
this reason, the OECD has classified the Finnish health system as one the most unequal in
the industrial countries.
In many other European countries, the wealthiest can skip the waiting queues in the public
system by buying private healthcare, or can afford VHI (see Sections 1.4.5 and 1.3).
Distance to healthcare
As discussed in Section 1.4.3, geographical disparities in provision of healthcare may be
quite considerable in some countries. Figure 16 clearly shows that there are significant
differences between countries in terms of travelling time. In general, the problem is most
acute in Central and Eastern European countries, while respondents in the Western Europe
and Nordic countries barely mention this factor (except for Iceland 0.3%, Denmark 0.1%
and Italy 0.1%). There is a substantial match between the countries for which people
report unmet needs for medical examination due to travelling time, and the countries for

Inequalities in access to healthcare A study of national policies
43
which ESPN experts highlighted important disparities in the supply of health services across
urban and rural areas (e.g. BG, CZ, EL, HR, HU, LT, LV, RO, RS, TR).
Figure 16: Self-reported unmet needs for medical examination due to travelling time (2016)
Source: Eurostat [hlth_silc_08]; * ESPN countries not included in the dataset: LI; ** Data for IS and TR refer to 2015, no data available for
2016.
Regional differences in access to care may be particularly high in countries where
competences for the organisation of healthcare have been (partially) devolved to the
regions.
For instance, in an Italian national survey, the share of individuals declaring unmet
healthcare needs in Southern Italy is twice as high as in Northern Italy: 9.4% versus 4.7%.
There are also wide gaps between the share of Italians accessing dental care by macro-
region: around 52% in Northern Italy and around 36% in Southern Italy. Waiting lists and
problems linked to travel distances to healthcare centres are also more widespread in
Southern (and Central) Italy than in Northern Italy. According to the Italian ESPN experts,
it is hard to provide an explanation for this gap. It is not simply related to regional
differences in public healthcare per-capita spending. The North-South difference in
performance of the system also seems to be due to differences in administrative and
organisational capacities, and the ability of regional and local administrations to manage
healthcare efficiently and effectively.
In Sweden, successful access levels differ between the regions, in particular between the
Northern region and the Stockholm region, regarding specialist care. The success rate for
getting an appointment with a specialist within 90 days was 67% in the Northern region
and 94% in the Stockholm region, and the likelihood of having an intervention within 90
days of a decision to operate was only around 60% in the Northern region and 87% in the
Stockholm region.
In Spain, while in Madrid patients had to wait 46 days on average for a non-urgent hospital
surgical intervention in June 2017, patients in the Canary Islands had to wait 169 days.
Waiting times for neurosurgical interventions can be as much as 317 days in the Canary
Islands, 229 days in Castile-La Mancha, 114 days in Valencia, compared to 52 days in
Madrid.
Out-of-pocket payments
The issue of affordability of healthcare has already been partially discussed in Section
2.1.1, in relation to low income groups. It is, however, worth examining out-of-pocket
payments (OOP) as a share of household expenditure in more detail: OOP medical spending
levels as a share of overall household consumption are quite significant in most European
countries. Bulgaria (5.8%), Malta (4.4%), Cyprus (4.4%) and Greece (4%) have figures

Inequalities in access to healthcare A study of national policies
44
(almost) double the EU average of 2.3%. As for the non-EU countries, those with the
highest percentages of OOP are Serbia, Switzerland, FYR of Macedonia, Iceland and
Norway. Of the 35 countries under scrutiny, Luxembourg (1.2%), Turkey (1.3%), France
(1.4%), the UK (1.5%), Germany (1.8%) and Romania (1.7%) have the lowest scores in
this respect (see Figure 17).
Figure 17: Out-of-pocket medical spending as a share of final household consumption, 2014 (or
nearest year)
Source: OECD/EU (2016), Health at a Glance: Europe 2016; * ESPN countries not included in the dataset: LI.
In general, the share of OOP spent on pharmaceuticals is among the most significant (see
Figure 18). This is especially true for Central and Eastern European countries (e.g. CZ, EE,
HR, HU, PL, RO, LV, SK), Greece and Iceland. In Romania, pharmaceuticals account for
75% of total out-of-pocket medical spending on services and goods, although this relates
to a very low level of OOP as a share of household consumption (see Figure 17). The share
of OOP for curative care is high in Austria, Belgium, Greece and Switzerland. The share of
OOP is highest for dental care in some Nordic countries (e.g. DK, IS, NO) and Southern
countries (e.g. ES). In these countries, dental care (for adults) is not included in the
healthcare basket (see Section 1.2.3).
The low coverage of some services and products, and in particular the high user charges
for medicines, but also dental care and mental healthcare, are a cause of concern in most
European countries (e.g. AT, BE, EE, EL, ES, FI, HR, HU, IE, IS, IT, LI, LT, LV, MT, NO, PL,
PT, RO, SE, SK). In particular, the fact that in many countries vulnerable groups are not
protected from high user charges for pharmaceuticals, and that pharmaceuticals are often
exempted from annual caps on user charges, may have an important impact on the
effectiveness of the healthcare provided. If a patient has access to a medical doctor but
cannot afford to pay for the prescribed medication, the care provided may be ineffective.
It should be noted that access to pharmaceutical products is not measured in the EU-SILC
data on self-reported unmet needs.

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Figure 18: Shares of out-of-pocket medical spending by services and goods, 2015 (or nearest year)
Source: OECD (2017), Health at a Glance 2017. Note: This indicator relates to current health spending excluding long-term care (health)
expenditure. 1Including eye care products, hearing aids, wheelchairs, etc. 2Includes home care and ancillary services (and dental if not shown
separately). 3Including day care. * ESPN countries not included in the dataset: BG, CY, HR, LI, LT, MK, MT, RO, RS, TR.
Several ESPN experts point to the issue of “catastrophic” health expenditure (e.g. CY, EL,
HU, LV, PT), in relation to the existence of high OOPs. The “catastrophic” label mainly
refers to the fact that falling ill can induce often sizeable and unpredictable shocks to a
household’s living standards, pushing many of them into poverty
31
. Moreover, these are
particularly problematic for low-income groups (e.g. CY, HR) and other vulnerable
categories, such as pensioners. For some examples, see Box 12.
Box 12: OOPs and catastrophic health expenditure: poor access
to healthcare for poorer population groups
Out-of-pocket payments in Cyprus are heavily skewed towards the lowest income group
(poorest 20% of the population). In addition, the proportion of households experiencing
catastrophic payments was higher for those having only public coverage than for households
having other types of coverage (i.e. combination of public and private coverage or only private).
The predominant determining factor for this is the limited access to public health services due
to long waiting lists, which results in catastrophic expenditure for a significant proportion of
low-income households as they are forced to seek health services in the private sector.
In Hungary, OOPs and catastrophic payments are often linked to informal payments and are
estimated to make up at least 2.1% of total health expenditure — a much higher share than in
most EU countries. They are often used to gain quicker access to healthcare and better-quality
care. In 2014, catastrophic medical expenditure affected 21.6% of households, and especially
those in the lowest income quintiles: 92.1% in the lowest, 9.0% in the second lowest and 1.7%
in the top income quintile. Between 2011-2014 both the proportion of OOPs and those affected
by catastrophic medical expenditure increased, while state support for prescription medicine
decreased.
31
Catastrophic health expenditure is defined in relation to a households’ capacity to pay. K. Xu et al. (2003), defined expenditure as being
“catastrophic” if a household’s financial contributions to the health system exceed 40% of income remaining after subsistence needs have
been met (the threshold at which health spending has been defined as “catastrophic” varies from 5% to 20% of total family income in other
studies).

Inequalities in access to healthcare A study of national policies
46
In Latvia, nearly 27% of the poorest fifth of households experienced catastrophic out-of-pocket
payments, compared to 4% of the richest fifth. Out-of-pocket payments for outpatient
medicines and medical products are the single largest cause of financial hardship, accounting
for 75% of catastrophic out-of-pocket payments on average in 2013 and rising to over 80% of
catastrophic out-of-pocket payments among the poorest half of the population.
In Poland, out-of-pocket (OOP) payments create a considerable burden for families and
individuals on low incomes. Catastrophic OOP health expenses, estimated as 10% of total
income, were experienced by every fifth household in Poland in 2010 (20.3%) and 8.8% of
households experienced expenditures amounting to 40% of their total capacity to pay. About
60% of OOP payments are for pharmaceuticals, 11-12% are used for paying for private doctors’
consultations and 14-16% for dental care.
Source: ESPN country reports
2.1.4 Wrapping up: strengths and weaknesses of healthcare systems in
ensuring access to healthcare
Most countries whose system is described by their national ESPN experts as underfunded
(e.g. BG, CY, EE, EL, HR, HU, IE, IT, LT, LV, PL, RO, RS) score less than the EU average
with regard to both access to healthcare and inequalities in access to healthcare between
income groups, as measured using the EU-SILC data on self-reported unmet needs for
healthcare (see Figure A3 in Annex 1). In underfunded systems, important shares of the
cost of services must be paid by the patient or the insured person, and there are large
variations in the availability and quality of services, which may lead to long waiting lists.
However, even between countries spending similar amounts of public money, the outcome
with regard to access to healthcare can be quite different. Some countries with below EU
average public spending on healthcare as a proportion of GDP perform rather well with
regard to access to healthcare and inequalities in access to healthcare among income
groups, based on the data on self-reported unmet needs for medical examination (e.g. CZ,
ES, UK). Although the qualitative data in the national reports do not allow us to draw robust
conclusions explaining why this is the case, the relatively low user charges for health
services (as discussed in Section 1.2.3) seem to play an important role here. This
hypothesis is supported by the country scores on unmet needs for dental care, where the
picture is quite different from that relating to unmet needs for medical examination, and
this in turn correlates with the level of user charges in the respective countries.
Moreover, inequalities in access to healthcare do not seem to be linked to the model of
health system funding. Well-performing countries can be found among all three models:
for example, Austria and Luxemburg among the countries with a Social Health Insurance
(SHI) system; the Netherlands with a compulsory Private Health Insurance (PHI) system;
and Spain and Norway with a National Health Service (NHS). This suggests that the success
of systems in terms of access is related, rather, to the country-specific details of financing
and organisation of healthcare provision and funding, and the way in which vulnerable
groups are protected from user charges within each of the systems.
Many ESPN experts warned that the (growth of) voluntary and occupational health
insurance could exacerbate inequalities in access to healthcare, in particular when the
schemes are used to “jump the queue” by those who can afford it, usually those in better
employment situations. VHI schemes risk reducing public support for measures aimed at
improving affordability of healthcare or improving waiting times for the whole population.
The schemes furthermore provide an incentive for health professionals to leave the
contracting system and to freely set their tariffs.
The unequal distribution of health services between urban and rural areas has been
highlighted for most countries (see Section 1.4.3) and cuts across health systems and
countries in Europe. The reasons for this geographical divide are multiple. Some of the

Inequalities in access to healthcare A study of national policies
47
factors behind these inequalities are not specific to health services but are typical for
services of general interest. Access to these services has to be guaranteed by the public
authorities, even in areas and circumstances where they cannot be financially viable, due
to long distances and low numbers of clients/patients. Other factors are specific to
healthcare. In particular and increasingly, quality of healthcare provision requires a certain
concentration of knowledge and experience, which is hard to guarantee in remote and
sparsely populated areas. For highly specialised care, high investment costs may be a
further challenging factor. Several ESPN country reports highlighted the resistance to plans
to close hospitals in remote areas, as part of policies to concentrate human and
technological resources (e.g. BE, LT, RO, SI).
2.2 Recent and planned reforms
Five countries recently implemented or plan a comprehensive reform, involving an
important overhaul of their health system: Cyprus, Greece, Finland, Ireland and Latvia
(see Box 13). These are the countries for which ESPN country experts highlighted that the
health system is fragmented, with different insurance coverage for different population
groups, serious gaps in health coverage and important inequalities in access to healthcare.
The main features of the reforms in these countries are:
 a move towards universal population coverage (e.g. CY, EL);
 an extension of the benefit package to a comprehensive range of services (e.g.
IE, LV);
 generation of additional resources by shifting from a state-funded system to a
contribution-based compulsory social health insurance system (e.g.CY, LV);
 a reduction in fragmentation in health funding bodies (e.g. EL, FI);
 greater integration between social and health services, in particular in
ambulatory settings (e.g. EL, FI, IE);
 an increased role for private providers in healthcare delivery (e.g. FI).
Box 13: Comprehensive system reforms in some countries
In Cyprus, a new National Health Service (NHS) will be implemented by 2020, after the country
has sought to implement a universal health system for nearly 30 years. The scheme will provide
universal population coverage and will be financed by state revenues and compulsory
contributions levied on wages, incomes and pensions. User charges will apply, with an annual
ceiling. The new system is expected to resolve the majority of the deficiencies of the current
system.
In Finland, the planned social and healthcare reform (SOTE) will: a) restrict the national health
insurance, one of the three historical legacies; b) increase the role of private players vis-à-vis
public providers in healthcare delivery; and c) shift powers for health provision from
municipalities towards new counties/regions, with a view to creating seamless service chains
for the provision of key social welfare and health services. However, rather surprisingly, the
occupational health insurance scheme, which was considered to be the major cause of
differences in access to healthcare, will remain intact. The ambition is to have SOTE
implemented by 2020. While, according to the Finnish ESPN expert, the SOTE reform has much
potential to create more equal access to healthcare, there are many risks as well. It may create
new inequalities between urban and rural areas and between high- and low-resource groups,
between those in the labour market and those who are inactive.
In Greece, since 2011, the newly created National Organisation for the Provision of Health
Services (EOPYY) has brought together all the health branches of most social insurance funds.
Since 2016 it has also covered the uninsured segment of the population, which is considered
an important step towards universal health coverage. The whole (previously extremely
fragmented) system for the provision of health services is now underpinned by a unified
regulation (Unified Healthcare Regulation-EKPY). Furthermore, a reform of the Greek primary
health system, which is currently underway, includes the establishment of “local health units”,
consisting of a multidisciplinary team of social and health workers. It is considered a positive

Inequalities in access to healthcare A study of national policies
48
development which has long been awaited. However, the progress of implementation is rather
slow, while understaffing continues to be a serious obstacle to the proper functioning of the
whole primary health system in Greece.
In Ireland there has been broad agreement for some time that the health system needs to be
reformed and the direction of travel is towards universal healthcare. However, proposals to this
effect failed for many reasons: these include the potential costs associated with the reform,
under-specification of key mechanisms and opposition from many interest groups. In 2017, an
all-party parliamentary committee provided a blue-print for universal healthcare, that would
give all residents access to a comprehensive range of services. Other recommendations include
the introduction of a new model of integrated and coordinated health and social care. While the
Irish government welcomed the report at the time, little has happened in the interim to
implement it.
Latvia will shift from a state-funded system to a compulsory health insurance system in 2019.
The reform aims to address the underfinancing problems of the system and to increase access
to state-funded health services. Persons who pay social contributions and groups of the
population for whom health insurance contributions will be paid by the state will have access
to a broad basket of benefits. According to the Latvian national ESPN experts, there is, however,
considerable uncertainty about the reform. It is feared that the new approach may jeopardize
accessibility of healthcare for those who are not insured. The law will furthermore not resolve
the issue of the high ratio of out-of-pocket payments made by the population.
Source: ESPN country reports
Other specific reforms were recently implemented or planned in many European countries.
These include:
 Increase of the overall budget for the health system, in particular to improve
the attractiveness of the health professions and reduce waiting times (e.g. CZ, EE,
LV, PL)
32
. Additionally, the systemic reforms in Cyprus and Latvia discussed above
– transforming the state-funded health system into a contribution-based
compulsory social health insurance system – also primarily aim to generate
additional resources. The additional resources in these two countries aim primarily
to ensure universal population coverage and to broaden the benefit package. In
Liechtenstein, however, the state contribution to the compulsory PHI fell steadily
until 2018.
 Improved availability of health professionals (e.g. CZ, DE, LT, LV, PL, RO, SI)
by increasing wages; by providing incentives to work in outpatient care, general
medicine and in poorly-serviced areas; through incentives to re-enter the labour
force and through additional financing of rural health centres.
 Improved availability of specific health services (e.g. BE, BG, HU, IS, PL, PT):
this includes, in particular, investment in mental health services and dental care.
Furthermore, measures have been taken to improve hospital funding mechanisms,
intra-hospital referrals, and the transition from hospital care to outpatient care. In
Turkey, additional hospitals have been opening since 2015.
 Improved access to primary care (e.g. EL, IT, PL, RO, UK), in particular in
remote areas, through: financial incentives; initiatives to shift from inpatient care
to outpatient and primary care; and the setting up of multidisciplinary integrated
primary care centres.
 Improved waiting list management (e.g. BG, DE, HU, LT, LV, MK, PT, SI, TR)
through the introduction of official waiting lists and maximum waiting time
guarantees, in particular for cancer patients.
 In addition to the countries mentioned above, which have enacted major reforms
aimed at providing universal population coverage (e.g. EL, LV, CY), other countries
32
This is also the case in Spain, under the new government (June 2018).

Inequalities in access to healthcare A study of national policies
49
improved population coverage for specific groups (e.g. EE, RO)
33
. By contrast,
in Bulgaria, citizens’ disrupted health insurance will in the future be restored only
subject to payment of arrears for the previous five years, instead of the 3 years
applicable until the end of 2015.
 Limits on specific user charges (e.g. BE, EE, IS, IT, LT, LU, RS, SK, PL, PT)
34
:
this includes reduced user charges for specific medical devices and pharmaceuticals
and exemptions from co-payments for the elderly. Initiatives have also been taken
to tackle informal payments and increase transparency (e.g. LT, RS), and up-front
payments for outpatient medical care have been abolished for lower income groups
(e.g. LU). Measures were taken (e.g. BE) to identify beneficiaries and to invite them
to apply for exemptions from user charges. Some of the measures taken reverse
increases in user charges enacted during the crisis years. However, in SK, the
maximum limit for co-payments has been increased while the groups of patients
subject to these maximum limits have been extended.
 Fostering prevention and health promotion (e.g. AT, BG, IT, HU, RO), by new
specific screening programmes and vaccinations. By contrast, in the UK,
despite strong advocacy of prevention, the public health budget has been severely
cut since 2015 and more spending cuts are planned.
 In France, coverage of voluntary health insurance was extended to nearly the
whole population, to cover the high user charges in the statutory system.
 Improved access for ethnic minorities (e.g. BE, MK, RO, SI). This includes
community nurses providing basic healthcare and intercultural mediators.
 Improved monitoring of access to healthcare and waiting lists (e.g. IT, SI,
UK).
33
And in Spain since the new government has been in power (June 2018).
34
And in Spain since the new government has been in power.

Inequalities in access to healthcare A study of national policies
50
3 The measurement of inequalities in access to healthcare
This final section provides a brief discussion of the measurement of inequalities in access
to healthcare. Measuring the accessibility of healthcare requires consideration of various
factors, related both to the health system and to the patients (Allin and Masseria 2009).
From that perspective, factors such as the design of statutory healthcare, coverage and
the public benefits packages, human resources, waiting times, continuity of care, the
quality of healthcare, as well as socio-economic status, the age of the patients and the
level of health literacy should be taken into consideration (Ibid).
Different approaches and indicators are available to measure the accessibility of healthcare
and to assess the extent of inequality in access to services. As illustrated above, the most
common approach to monitoring inequalities in access to healthcare is through a proxy
indicator on the self-reported unmet needs for medical care. The main source in Europe is
the EU Statistics on Income and Living Conditions (EU-SILC). Although this indicator,
commonly used in the EU
35
, has the undeniable advantage of facilitating cross-country
comparisons and providing a first indication of inequalities and problems regarding
affordability and accessibility, many ESPN experts have pointed to its limitations and
emphasised the need for caution in interpreting the results (e.g. AT, BE, BG, CY, DE, EE,
EL, ES, HR, IT, LV, PT, MT, NL, NO, SE, SI, SK) (see also EXPH 2016; European Commission
2017).
ESPN experts primarily express concerns regarding the variation in the results between
surveys, wording issues, and the lack of consistency with national data on accessibility of
health services. However, major progress has already been made regarding the
harmonisation of health-related questions between countries (notably based on
collaboration between the EU-SILC and EHIS teams). Some changes in the guidelines and
model questions in the EU-SILC survey were notably introduced in 2015 (European
Commission 2017). But there is still some room for improvement. For example, the
Swedish ESPN expert raises the issue of the falling response rate, in general and for
disadvantaged groups, of most national health surveys. In relation to variables that are
associated with non-response, such as unmet needs, the overall figure for the population
may be seriously underestimated. The “report on the comparative assessment of the
accessibility of healthcare services” focused mainly on translation issues as a potential
cause of comparability issues for the EU-SILC data on unmet needs for medical
examination or treatment across Member States. It also raised the need to further
investigate cultural aspects, since responses vary according to cultural differences in the
perception of health (European Commission 2017).
Alongside the indicator on unmet needs for medical care, which is primarily a broad proxy
indicator on the issue, complementary indicators are useful and needed in order to paint a
subtler and more comprehensive picture of the situation (e.g. AT, CY, FI, HR, HU, IE, MK,
NO). ESPN experts emphasise the existence of a wide range of indicators (covering, among
others, the three main domains of access – coverage, availability and affordability) already
available in Europe and internationally and refer to their valuable insights. Some examples
have been reported by ESPN experts. OECD measures, such as the OECD Horizontal
inequity index
36
, can be of great value; this index examines the extent to which the use of
health services, based on standardised needs, differs among different income groups in
various countries. ESPN experts also referred to data available in the European Social
35
Various surveys include questions on self-reported unmet need for medical care: the EU Statistics on Income and Living Conditions (EU-
SILC), the European Health Interview Survey (EHIS), the Eurofound Quality of Life Survey (EQLS), the Survey of Health, Ageing and
Retirement in Europe (SHARE) and the European Social Survey (ESS).
36
Estimates are based on national health interview surveys/ European Health Interview Survey. See OECD (2013), and Devaux and de
Looper (2012) for complementary information. Data is compiled on an ad-hoc basis and is based on 2009 data. Covers selected OECD
countries.

Inequalities in access to healthcare A study of national policies
51
Survey
37
, in the EU-SILC special ad-hoc module
38
, and WHO indicators on health
inequities
39
, which make it possible to directly measure inequalities in access to healthcare,
from a comparative perspective. Access to healthcare can also be evaluated indirectly by
considering outcomes related to healthcare (see also EXPH 2017). Existing data comprise
various health outcome indicators (child mortality, amenable mortality, preventable
mortality, external causes of death excluding transport accidents, etc.) (see European
Commission 2015, p.16-19). Data related to inputs, process and outcomes are notably
available in the regular “Health at a glance” reports produced by the OECD and the EU
(OECD/EU 2016; OECD 2017).
For additional information on some international standardised indicators, see Boxes 14a,
14b and 14c.
Box 14a: Additional information on international standardised indicators
(2016 and 2017 EU-SILC ad hoc modules)
EU-SILC ad hoc module on access to services (2016)
Persons using healthcare services by household type, income group and level of difficulty to
afford care services (ilc_ats12)
Three questions are used to assess access to healthcare (available here):
- Has the household used any healthcare services during the last 12 months (e.g.
consultations, treatment and prescribed medication) (at the household level)? (HC160)
Yes / No. If “No”, go to question HC190
- Has the household paid or contributed to the cost of healthcare services during the last
12 months? (HC170) Yes / No.
- Level of difficulty experienced by the household in covering the total healthcare services
costs (costs of consultations, treatment and prescribed medication; dental examination
or treatment) for all the household members (including former members) (HC180).
Answers: great difficulty, difficulty, some difficulty, fairly easily, easily, very easily.
It should be noted that households that were not able to use healthcare services during the
last 12 months (e.g. due to financial problems, waiting lists, etc.) are not taken into account in
this indicator.
EU-SILC ad hoc module on health and children’s health (2017)
This module includes the following questions related to access to healthcare for households
with children:
Information on financial burden (refers to the household)
- To what extent were the costs of medical examinations or treatments a financial burden
to your household during the past 12 months (excluding dental examinations or
treatments)? (HS200)
- To what extent were the costs of dental examinations or treatments a financial burden
to your household during the past 12 months? (HS210)
- To what extent were the costs of medicines (prescribed and non-prescribed) a financial
burden to your household during the past 12 months? (HS220)
37
European Social Survey: the core module takes place every two years (2002-2016). Geographical coverage varies over time: see the list of
participating countries for each round (year). Rotating modules are dedicated to specific themes and are collected on an ad-hoc basis. See
for example: Social inequalities in health (2014) – data available for EU countries (AT, BE, CZ, DK, EE, FI, FR, DE, HU, IE, LV, LT, NL, PL, PT, SI,
ES, SE, UK) and non-EU countries (Israel (IL), NO, CH) – and: Health and care seeking (2004).
38
2016 EU-SILC ad hoc module on access to services. Countries covered: EU Member States and IS, NO, CH and TR.
39
WHO indicators: see for example: List of 100 core health indicators (2015), Health systems data, Universal health coverage data, Health
equity monitor and European Health Information Gateway: Health for All explorer: 1503 indicators. Periodicity and geographical coverage
vary according to the indicator and the data set.

Inequalities in access to healthcare A study of national policies
52
Information on health (provided for each household member)
- During the past 12 months, how many times did you visit a dentist or orthodontist on
your own behalf (PH080)?
- During the past 12 months, how many times did you consult a GP (general practitioner)
or family doctor on your own behalf? (PH090)
- During the past 12 months, how many times did you consult a medical or surgical
specialist on your own behalf? (PH100)
Information on unmet need (refers to children aged 0-15 living in the household)
- Was there any time during the past 12 months when [any of] your child[ren]really
needed medical examination or treatment (excluding dental examination or
treatment)? (HC010 Q1). If “Yes”, go to question HC010 Q2. If “No”, go to question
HC030
- Did your child[ren] have a medical examination or treatment each time it was really
needed? (HC010 Q2). If “Yes”, go to question HC030. If “No”, go to question HC020.
- What was the main reason for not having a medical examination or treatment?
Answers: could not afford to (too expensive), waiting list or the time needed to obtain
an appointment was too long, could not take the time, because of work, care of other
children or of other persons, too far to travel or no means of transportation, other
reason (HC020)
- Was there any time during the past 12 months when [any of] your child[ren] really
needed dental examination or treatments (HC030_Q1). If “Yes”, go to question
HC030_Q2. If “No”, go to question HC040
- Did your child[ren] have a dental examination or treatment each time it was really
needed? (HC030_Q2)
- What was the main reason for not having a dental examination or treatment? Answers:
could not afford to (too expensive), waiting list or the time needed to obtain an
appointment was too long, could not take the time, because of work, care of other
children or of other persons, too far to travel or no means of transportation, other
reason (HC040)
Source: authors’ own elaboration
Box 14b: Additional information on international standardised indicators
(OECD Horizontal inequity index)
OECD Horizontal inequity index
This indicator compares the observed distribution of healthcare by income with the distribution
of need (Devaux and de Looper, 2012).
“Inequalities in the probability and the number of doctor consultations across different socio-
economic groups must take into account differences in need, because health problems are more
frequent and more severe among lower socio-economic groups. The adjustment for need
provides a better measure of inequity” (OECD, 2013, p. 144)
Based on different variables (see Devaux and de Looper, 2012):
- Doctor (specialist/GP) visits in the past 12 months
- Dentist visits in the past 12 months
- Need for healthcare
- Individual characteristics
- Income level of the household
Source: authors’ own elaboration

Inequalities in access to healthcare A study of national policies
53
Box 14c: Additional information on international standardised indicators
(European Social Survey and WHO Health Equity Monitor)
European Social Survey
Core module
- Please say what you think overall about the state of health services in [country]
nowadays?
- How is your health in general?
- Are you hampered in your daily activities in any way by any longstanding illness, or
disability, infirmity or mental health problem?
Rotating module (2014 social inequalities in health)
Use of primary, secondary and alternative healthcare:
- Discussed health, last 12 months with general practitioner, medical specialist, none of
these (E13)
- Unable to get medical consultation or treatment, last 12 months (E14)
- Reason for no medical consultation or treatment: could not pay, could not take time off
work, other commitments, not available where you live, waiting list too long, no
appointments available (E15)
- Never able to get medical consultation or treatment, reason, last 12 months (E16)
- Treatments used for own health, last 12 months: acupuncture, acupressure, Chinese
medicine, chiropractic, osteopathy, homeopathy, herbal treatment, hypnotherapy,
massage therapy, physiotherapy, reflexology, spiritual healing (E19)
See here for complementary information
WHO Health Equity Monitor
Inequality in reproductive, maternal, new-born and child health (RMNCH) interventions,
combined: composite coverage index of RMNCH interventions capturing both the provision and
use of key RMNCH interventions
Source: authors’ own elaboration
ESPN national reports also reflect the data available (on coverage, availability and
affordability) at national level. This information enables us to understand some country
specificities and enriches the standardised indicators (see Box 15). For instance, the Dutch
experts highlight that in the case of the Netherlands, the structure of financing needs to
be considered (especially the arrangements for deductibles, although this aspect is not
included in international indicators). Some countries (e.g. CH, CZ, DK, SE) have a strong
history of developing indicators that can be broken down into sub-areas (regional,
municipalities…). So far, however, regional discrepancies are barely revealed in
international indicators. In Denmark, the National Action Plan has about 30 indicators
which make it possible to compare health inequities across regions and municipalities. In
Sweden, the “Open Comparisons” produced by the Swedish Association of Local Authorities
and Regions (SALAR) and the National Board of Health and Welfare (NBHW) provide
comparisons between municipalities and counties.
With regard to the indicators available to measure health coverage, which range from
administrative data at national level to international standardised indicators (such as the
OECD indicators), some ESPN experts point to the lack of information on group differences
(e.g. EL, ES), especially for those which are excluded from the system (e.g. ES). Some
experts also emphasise that national and Eurostat measures are not always the same. In
Denmark, national and Eurostat measures of private health insurance coverage differ.
Indicators to assess the availability of health services are usually split into two distinct
topics – geographical distribution of doctors and waiting times/waiting lists (e.g. DE, ES,
FR). Some ESPN experts highlight issues when it comes to measuring affordability. For

Inequalities in access to healthcare A study of national policies
54
example, in Greece, out-of-pocket payments are underestimated, since the extensive use
of informal payments for healthcare is not taken into account.
The challenge of measuring inequalities in access to healthcare is also linked to the lack of
indicators and access to reliable and quality data at national level. Some countries are still
facing difficulties in gathering regular, quality data (e.g. BG, CY, EL, LI, LV).
Box 15: Examples of national initiatives to produce data related
to inequality in access to healthcare
In Finland, the different registers (on income, education, socio-economic status, language,
diagnoses, the utilisation of health services and the use of medicine), besides providing rich
data, make it possible to directly evaluate the state of health and the utilisation of services.
In France, an indicator of disparities in healthcare availability or “localised potential
accessibility” has been developed. This indicator combines a measurement of the distance to
the closest health professional with the level of the practitioner’s activity, using full-time
equivalents and healthcare requests that consider different needs depending on age.
Ireland has developed a number of initiatives to produce analyses related to health inequalities:
the Irish Health Poverty Index of the Institute of Public Health in Ireland; the Health Atlas
Ireland, and the Pobal maps — a free geographical information system (GIS) which provides
local area deprivation and service profiling.
In Lithuania, following the impetus of the project “Development of the Model for the
Strengthening of the Capacities to reduce Health Inequalities”, a system for monitoring
healthcare inequalities has been developed. There are various types of indicators: demographic,
economic, social indicators; indicators on mortality, morbidity and access to health services
and indicators based on data from population surveys.
Source: ESPN country reports

Inequalities in access to healthcare A study of national policies
55
ANNEX 1: FIGURES
Figure A1: Self-reported unmet needs for medical examination: trends in selected countries with
increasing trends (2008-2016)
Source: Eurostat [hlth_silc_08].
Figure A2: Self-reported unmet needs for medical examination: trends in selected countries with
decreasing trends (2008-2016)
Source: Eurostat [hlth_silc_08].
0
2
4
6
8
10
12
14
16
2008 2009 2010 2011 2012 2013 2014 2015 2016
% Population 16+
EU BE EE EL IS FI

Inequalities in access to healthcare A study of national policies
56
Figure A3: Self-reported unmet needs for medical examination due to cost, waiting time and
travelling distance by income quintile (2016)
Source: Eurostat [hlth_silc_08]; * ESPN countries not included in the dataset: LI; ** ESPN countries with no data for the year considered in
the graph: IS, TR.

Inequalities in access to healthcare A study of national policies
57
ANNEX 2: OFFICIAL COUNTRY ABBREVIATIONS
A. EU countries
EU countries prior to
2004, 2007 and 2013
Enlargements (EU-15)
EU countries that joined
in 2004, 2007
or 2013
BE
Belgium
2004 Enlargement
DK
Denmark
CZ
Czech Republic
DE
Germany
EE
Estonia
IE
Ireland
CY
Cyprus
EL
Greece
LV
Latvia
ES
Spain
LT
Lithuania
FR
France
HU
Hungary
IT
Italy
MT
Malta
LU
Luxembourg
PL
Poland
NL
The Netherlands
SI
Slovenia
AT
Austria
SK
Slovakia
PT
Portugal
FI
Finland
2007 Enlargement
SE
Sweden
BG
Bulgaria
UK
United Kingdom
RO
Romania
2013 Enlargement
HR
Croatia
In EU averages, countries are weighted by their population sizes.
B. Non-EU countries covered by the ESPN
Former Yugoslav Republic of Macedonia (MK), Iceland (IS), Liechtenstein (LI), Norway
(NO), Serbia (RS), Switzerland (CH) and Turkey (TR).

Inequalities in access to healthcare A study of national policies
58
ANNEX 3: REFERENCES
Allin, S. and Masseria, C. (2009), Research Note: Unmet need as an indicator of access to
health care in Europe. Available online.
Ahrendt, D. et al. (2018), European Quality of Life Survey 2016. Eurofound, 122 p.
Devaux, M. and M. de Looper (2012), Income-Related Inequalities in Health Service
Utilisation in 19 OECD Countries, 2008-2009, OECD Health Working Papers, No. 58,
OECD Publishing, Paris
Dubois, H. and Molinuevo, D. (2014), Access to healthcare in times of crisis. Eurofound,
76 p.
European Commission (2014), Communication from the Commission on effective,
accessible and resilient health systems. COM (2014)215 final. Available online.
European Commission (2015), Towards a Joint Assessment Framework in the Area of
Health - Work in progress: 2015 update.
European Commission (2017), Report on the comparative assessment on the accessibility
of health services: comparability of indicators on unmet needs for medical examination
or treatment across EU Member States. Written by the consortium of Ecorys Nederland
B.V., Erasmus University Rotterdam and GFK Belgium, Luxembourg: Publications Office
of the European Union.
EXPH (EXpert Panel on effective ways of investing in Health) (2016), Access to health
services in the European Union — Final opinion. Expert panel on effective ways of
investing in health, European Commission. Available online.
EXPH (2017), Opinion on Benchmarking Access to Healthcare in the EU. European
Commission. Available online.
European Parliament and Council of the EU (2011), Directive 2011/24/EU of the European
Parliament and of the Council of 9 March 2011 on the application of patients’ rights in
cross-border healthcare. OJ L 88/45-65, 4 April 2011.
OECD/EU (2016), Health at a Glance: Europe 2016 – State of Health in the EU Cycle. OECD
Publishing, Paris, 204 p. Available online
OECD (2013), Health at a Glance 2013: OECD Indicators. OECD Publishing, Paris, 213 p.
Available online.
OECD (2017), Health at a Glance 2017: OECD Indicators. OECD Publishing, Paris, 220 p.
Available online.
OECD/WHO/World Bank Group (2018), Delivering Quality Health Services: A Global
Imperative for universal health coverage. World Health Organization, Geneva 27, 100
p. Available online
Rechel, B., Thomson, S. and van Ginneken, E. (2010), Health Systems in Transition:
Template for authors. World Health Organization 2010, on behalf of the European
Observatory on Health Systems and Policies, Copenhagen, 110 p. Available online.
Siciliani, L., M. Borowitz and V. Moran (eds.) (2013), Waiting Time Policies in the Health
Sector: What Works? OECD Health Policy Studies, OECD Publishing. Available online
Xu, K. et al. (2003), Household catastrophic health expenditure: a multi-country analysis.
The Lancet. Vol (362):111-117.
Sagan, A. and Thomson, S. (2016), Voluntary health insurance in Europe: role and
regulation. World Health Organization 2010, on behalf of the European Observatory on
Health Systems and Policies, Copenhagen, 110 p. Available online.
SPC (2016), SPPM thematic reviews on the 2014 social trends to watch. Towards better
health through universal access to health care in the European Union. The Social
Protection Committee, 17 p.
WHO (2010), World Health Report 2010, Health Systems Financing: The Path to Universal
Coverage. World Health Organization, Geneva, 106 p. Available online

Inequalities in access to healthcare A study of national policies
59
ANNEX 4: Lists of boxes, figures and tables
List of boxes
Box 1 The impact of the crisis on public funding of healthcare in some countries
Box 2 Different schemes of statutory coverage for different population groups:
within-country variation
Box 3 Country examples on level of user charges
Box 4 Protecting vulnerable groups from user charges
Box 5 Country examples of implicit rationing of healthcare provision
Box 6 Country examples on waiting times and waiting time guarantees
Box 7 Interaction between physicians working in the public/contracted sector and
in the private sector
Box 8 Country examples on the link between occupational health insurance
coverage and inequalities in access to healthcare
Box 9 Access to healthcare for Roma: policy challenges and good practices
Box 10 Access to healthcare for asylum seekers and undocumented migrants: policy
challenges and good practices
Box 11 Inequalities in access to health promotion and preventive services
Box 12 OOPs and catastrophic health expenditure: poor access to healthcare for
poorer population groups
Box 13 Comprehensive system reforms in some countries
Box 14a Additional information on international standardised indicators (2016 and
2017 EU-SILC ad hoc modules)
Box 14b Additional information on international standardised indicators (OECD
Horizontal inequity index)
Box 14c Additional information on international standardised indicators (European
Social Survey and WHO Health Equity Monitor)
Box 15 Examples of national initiatives to produce data related to inequality in
access to healthcare
List of figures
Figure 1 Current health expenditure by type of financing, 2014
Figure 2 Health expenditure as a share of GDP, 2015 (or nearest year)
Figure 3 The dimensions of health coverage
Figure 4 Percentage of the population covered for a defined set of services, 2014 (or
nearest year)
Figure 5 Public share of spending on pharmaceuticals compared with health services,
2014 (or nearest year)
Figure 6 Self-reported unmet needs for medical examination due to cost, distance
and waiting time
Figure 7 Self-reported unmet needs for medical examination by main reasons (2016)
Figure 8 Self-reported unmet needs for medical examination due to cost by income
quintile (2016)
Figure 9 Self-reported unmet needs for dental examination due to cost (2016)

Inequalities in access to healthcare A study of national policies
60
Figure 10 Self-reported unmet needs for dental examination due to cost per income
quintile (2016)
Figure 11 Self-reported unmet needs for medical examination according to activity
status (2016)
Figure 12 Self-reported unmet needs for medical examination by gender, due to cost,
distance and waiting time, 2016
Figure 13 Persons using health services by household type and level of difficulty in
affording health services (EU28, 2016)
Figure 14 Self-reported unmet needs for medical examination due to waiting lists
(2008-2016)
Figure 15 Self-reported unmet needs for medical examination due to waiting times by
income quintile (2016)
Figure 16 Self-reported unmet needs for medical examination due to travelling time
(2016)
Figure 17 Out-of-pocket medical spending as a share of final household consumption,
2014 (or nearest year)
Figure 18 Shares of out-of-pocket medical spending by services and goods, 2015 (or
nearest year)
Figure A1 Self-reported unmet needs for medical examination: trends in selected
countries with increasing trends (2008-2016)
Figure A2 Self-reported unmet needs for medical examination: trends in selected
countries with decreasing trends (2008-2016)
Figure A3: Self-reported unmet needs for medical examination due to cost, waiting time
and travelling distance by income quintile (2016)
List of tables
Table 1 Models of health systems in Europe
Table 2 General policies on user charges in Europe

Inequalities in access to healthcare A study of national policies
61
ANNEX 5: PRESENTATION OF THE EUROPEAN SOCIAL POLICY
NETWORK (ESPN), July 2018
A. ESPN Network Management Team and Network Core Team
The European Social Policy Network (ESPN) is managed jointly by the Luxembourg Institute
of Socio-Economic Research (LISER) and the independent research company APPLICA, in
close association with the European Social Observatory.
The ESPN Network Management Team is responsible for the overall supervision and
coordination of the ESPN. It consists of five members:
NETWORK MANAGEMENT TEAM
Eric Marlier (LISER, LU)
Project Director
Email: eric.marlier@skynet.be
Hugh Frazer (National University of Ireland Maynooth, IE)
Independent Experts’ Coordinator and Social Inclusion Leader
Email: hughfrazer@eircom.net
Loredana Sementini (Applica, BE)
Communication/events and IT Coordinator
Email: LS@applica.be
Bart Vanhercke (European Social Observatory, BE)
Overall Social Protection Leader
Email: vanhercke@ose.be
Terry Ward (Applica, BE)
MISSOC Leader
Email:: TW@applica.be
The ESPN Network Core Team provides high level expertise and inputs on specific aspects
of the ESPN’s work. It consists of 14 experts:
NETWORK CORE TEAM
The five members of the Network Management Team
Rita Baeten (European Social Observatory, BE), Healthcare and Long-term care
Leader
Marcel Fink (Institute for Advanced Studies, Austria), MISSOC Users’ Perspective
Andy Fuller (Alphametrics), IT Leader
Anne-Catherine Guio (LISER, LU), Quantitative Analysis Leader, Knowledge Bank
Coordinator and Reference budget
Saskia Klosse (University of Maastricht, NL), MISSOC and International Social
Security Legal Expert
David Natali (Institute of Law, Politics and Development, Sant’Anna School of
Advanced Studies [Pisa, IT] and European Social Observatory [BE]), Pensions Leader
Monika Natter (ÖSB, AT), Peer Review Perspective
Stefán Ólafsson (University of Iceland, IS), MISSOC Users’ Perspective
Frank Vandenbroucke (University of Amsterdam), Decision-making Perspective

Inequalities in access to healthcare A study of national policies
62
B. ESPN national independent experts for social protection and social
inclusion
AUSTRIA
Marcel Fink (Institute for Advanced Studies)
Expert in Long-term care, Pensions and Social inclusion
Email: fink@ihs.ac.at
Monika Riedel (Institute for Advanced Studies)
Expert in Healthcare and Long-term care
Email: riedel@ihs.ac.at
National coordination: Marcel Fink
BELGIUM
Ides(bald) Nicaise (Research Institute for Work and Society – HIVA, KULeuven)
Expert in Social inclusion
Email: Ides.nicaise@kuleuven.be
Jozef Pacolet (Research Institute for Work and Society – HIVA, KULeuven)
Expert in Healthcare, Long-term care and Pensions
Email: jozef.pacolet@kuleuven.be
National coordination: Ides Nicaise
BULGARIA
George Bogdanov (Hotline ltd)
Expert in Social inclusion
Email: george@hotline-bg.com
Lidia Georgieva (Medical University Sofia)
Expert in Healthcare and Long-term care
Email: lidia1001@gmail.com
Boyan Zahariev (Open Society Foundation)
Expert in Pensions and Social inclusion
Email: bzahariev@osi.bg
National coordination: George Bogdanov
CROATIA
Paul Stubbs (The Institute of Economics)
Expert in Social inclusion
Email: pstubbs@eizg.hr
Ivana Vukorepa (University of Zagreb)
Expert in Pensions
Email: ivana.vukorepa@pravo.hr
Siniša Zrinščak (University of Zagreb)
Expert in Healthcare and Long-term care
Email: sinisa.zrinscak@pravo.hr
National coordination: Paul Stubbs

Inequalities in access to healthcare A study of national policies
63
CYPRUS
Marios Kantaris (Open University of Cyprus)
Expert in Long-term care
Email: marios.kantaris@st.ouc.ac.cy
Christos Koutsampelas (University of Cyprus)
Expert in Pensions and Social inclusion
Email: koutsampelas.christos@ucy.ac.cy
Mamas Theodorou (Open University of Cyprus)
Expert in Healthcare
Email: m.theodorou@ouc.ac.cy
National coordination: Christos Koutsampelas
CZECH REPUBLIC
Robert Jahoda (Masaryk University)
Expert in Pensions
Email: jahoda@econ.muni.cz
Ivan Malý (Masaryk University)
Expert in Healthcare and Long-term care
Email: ivan@econ.muni.cz
Tomáš Sirovátka (Masaryk University)
Expert in Long-term care and Social inclusion
Email: sirovatk@fss.muni.cz
National coordination: Tomáš Sirovátka
DENMARK
Jon Kvist (Roskilde University)
Expert in Long-term care, Pensions and Social inclusion
Email: jkvist@ruc.dk
Kjeld Møller Pedersen (University of Southern Denmark)
Expert in Healthcare
Email: kmp@sam.sdu.dk
National coordination: Jon Kvist
ESTONIA
Helen Biin (Praxis)
Expert in Social inclusion
Email: helen.biin@praxis.ee
Märt Masso (Praxis)
Expert in Social inclusion
Email: mart.masso@praxis.ee
Gerli Paat-Ahi (Praxis)
Expert in Healthcare and Long-term care
Email: gerli.paat-ahi@praxis.ee
Magnus Piirits (Praxis)
Expert in Pensions
Email: magnus.piirits@praxis.ee
National coordination: Märt Masso

Inequalities in access to healthcare A study of national policies
64
FINLAND
Laura Kalliomaa-Puha (Social Insurance Institution of Finland - Kela)
Expert in Healthcare and Long-term care
Email: laura.kalliomaa-puha@kela.fi
Olli Kangas (University of Turku)
Expert in Healthcare, Pensions and Social inclusion
Email: olli.kangas@utu.fin
National coordination: Olli Kangas
FRANCE
Gaby Bonnand (EHESP French School of Public Health)
Expert in Pensions
Email: Gaby.Bonnand@ehesp.fr
Gilles Huteau (EHESP French School of Public Health)
Expert in Healthcare
Email: Gilles.Huteau@ehesp.fr
Blanche Le Bihan (EHESP French School of Public Health)
Expert in Long-term care
Email: Blanche.Lebihan@ehesp.fr
Michel Legros (EHESP French School of Public Health & National Observatory on
Poverty and Social Exclusion)
Expert in Healthcare and Social inclusion
Email: Legrosmi@wanadoo.fr
Claude Martin (EHESP French School of Public Health)
Expert in Social policy
Email: Claude.Martin@ehesp.fr
National coordination: Claude Martin
GERMANY
Thomas Gerlinger (University of Bielefeld)
Expert in Healthcare and Long-term care
Email: thomas.gerlinger@uni-bielefeld.de
Walter Hanesch (Hochschule Darmstadt – University of Applied Sciences)
Expert in Social inclusion
Email: walter.hanesch@h-da.de
Jutta Schmitz (University of Duisburg/Essen)
Expert in Pensions
Email: Jutta.Schmitz@uni-due.de
National coordination: Walter Hanesch
GREECE
Yiannis Sakellis (Panteion University of Political and Social Sciences)
Expert in Healthcare and Long-term care
Email: ioannisakellis@gmail.com
Menelaos Theodoroulakis (Research Institute of Urban Environment and Human
Recourses)
Expert in Pensions
Email: mtheodor@pepsaee.gr
Dimitris Ziomas (Greek National Centre for Social Research – EKKE)
Expert in Long-term care and Social inclusion
Email: dziomas@ekke.gr
National coordination: Dimitris Ziomas

Inequalities in access to healthcare A study of national policies
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HUNGARY
Fruzsina Albert (Hungarian Academy of Sciences Center for Social Sciences and
Károli Gáspár University of the Reformed Church)
Expert in Healthcare and Social inclusion
Email: albert.fruzsina@gmail.com
Róbert Iván Gál (Demographic Research Institute, Central Statistical Office and
TÁRKI Social Research Institute)
Expert in Long-term care and Pensions
Email: gal@tarki.hu
National coordination: Fruzsina Albert
ICELAND
Tinna Ásgeirsdóttir (University of Iceland)
Expert in Healthcare and Long-term care
Email: ta@hi.is
Stefán Ólafsson (University of Iceland)
Expert in Healthcare, Long-term care, Pensions and Social inclusion
Email: olafsson@hi.is
Kolbeinm H. Stefánsson (University of Iceland and Statistics Iceland)
Expert in Social inclusion
Email: kolbeinn@hi.is
National coordination: Stefán Ólafsson
IRELAND
Sara Burke (Centre for Health Policy and Management, Trinity College Dublin)
Expert in Healthcare and Long-term care
Email: sarabur@gmail.com
Mary Daly (University of Oxford)
Expert in Social inclusion
Email: mary.daly@spi.ox.ac.uk
Gerard Hughes (School of Business, Trinity College Dublin)
Expert in Pensions
Email: gehughes@tcd.ie
National coordination: Mary Daly
ITALY
Matteo Jessoula (University of Milan)
Expert in Pensions
Email: matteo.jessoula@unimi.it
Marcello Natili (University of Milan)
Expert in Social inclusion
Email: m-natili@hotmail.it
Emmanuele Pavolini (Macerata University)
Expert in Healthcare and Long-term care
Email: emmanuele.pavolini@unimc.it
Michele Raitano (Sapienza University of Rome)
Expert in Social inclusion
Email: michele.raitano@uniroma1.it
National coordination: Matteo Jessoula

Inequalities in access to healthcare A study of national policies
66
LATVIA
Tana Lace (Riga Stradins University)
Expert in Healthcare and Social inclusion
Email: tanalace@inbox.lv
Feliciana Rajevska (Vidzeme University of Applied Sciences)
Expert in Long-term care and Pensions
Email: rajevska@latnet.lv
National coordination: Feliciana Rajevska
LIECHTENSTEIN
Patricia Hornich (Liechtenstein-Institut)
Expert in Healthcare, Long-term care, Pensions and Social inclusion
Email: patricia.hornich@liechtenstein-institut.li
Wilfried Marxer (Liechtenstein-Institut)
Expert in Healthcare, Long-term care, Pensions and Social inclusion
Email: wilfried.marxer@liechtenstein-institut.li
National coordination: Wilfried Marxer
LITHUANIA
Romas Lazutka (Vilnius University)
Expert in Pensions and Social inclusion
Email: romas.lazutka@fsf.vu.lt
Arūnas Poviliūnas (Vilnius University)
Expert in Healthcare and Social inclusion
Email: arunas.poviliunas@fsf.vu.lt
Laimute Zalimiene (Vilnius University)
Expert in Healthcare and Long-term care
Email: laima.zalimiene@fsf.vu.lt
National coordination: Arunas Poviliūnas
LUXEMBOURG
Jozef Pacolet (Research Institute for Work and Society, KULeuven)
Expert in Healthcare, Long-term care and Pensions
Email: jozef.pacolet@kuleuven.be
Hugo Swinnen (Independent social policy researcher)
Expert in Social inclusion
Email: hswinnen@home.nl
National coordination: Hugo Swinnen

Inequalities in access to healthcare A study of national policies
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FYR of MACEDONIA
Dragan Gjorgjev (Institute of Public Health and Public Health Department at the
Medical Faculty)
Expert in Healthcare and Long-term care
Email: dgjorgjev@gmail.com
Maja Gerovska Mitev (Institute of Social Work and Social Policy, Faculty of
Philosophy, Ss. Cyril and Methodius University)
Expert in Pensions and Social inclusion
Email: gerovska@fzf.ukim.edu.mk
National coordination: Maja Gerovska Mitev
MALTA
Anna Borg (University of Malta)
Expert in Children, Labour studies and Social inclusion
Email: anna.borg@um.edu.mt
Mario Vassallo (University of Malta)
Expert in Healthcare, Long-term care, Pensions and Social inclusion
Email: mario.vassallo@um.edu.mt
National coordination: Mario Vassallo
NETHERLANDS
Karen M. Anderson (University of Southampton)
Expert in Long-term care and Pensions
Email: K.M.Anderson@soton.ac.uk
Katrien de Vaan (Regioplan Policy Research)
Expert in Healthcare
Email: Katrien.de.vaan@regioplan.nl
Bob van Waveren (Regioplan Policy Research)
Expert in Social inclusion
Email: Bob.van.Waveren@regioplan.nl
National coordination: Bob van Waveren
NORWAY
Axel West Pedersen (Institute for Social Research)
Expert in Pensions and Social inclusion
Email: awp@samfunnsforskning.no
Anne Skevik Grødem (Institute for Social Research)
Expert in Social inclusion
Email: a.s.grodem@samfunnsforskning.no
Marijke Veenstra (Norwegian Social Research - NOVA)
Expert in Healthcare and Long-term care
Email: mve@nova.no
National coordination: Axel West Pedersen

Inequalities in access to healthcare A study of national policies
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POLAND
Agnieszka Chłoń-Domińczak (Warsaw School of Economics – SGH and Educational
Research Institute)
Expert in Pensions and Social inclusion
Email: Agnieszka.Chlon@gmail.com
Agnieszka Sowa (Institute of Labour and Social Affairs and Centre for Social and
Economic Research, CASE Foundation)
Expert in Healthcare and Long-term care
Email: Agnieszka.Sowa@case.com.pl.
Irena Topińska (Centre for Social and Economic Research, CASE Foundation)
Expert in Pensions and Social inclusion
Email: irena.topinska@case.com.pl
National coordination: Irena Topińska
PORTUGAL
Pedro Perista (Centro de Estudos para a Intervenção Social - CESIS)
Expert in Social inclusion
Email: pedro.perista@cesis.org
Céu Mateus (Division of Health Research, Lancaster University, Furness College)
Expert in Healthcare
Email: ceum@ensp.unl.pt
Heloísa Perista (Centro de Estudos para a Inclusão Social - CESIS)
Expert in Pensions and Social inclusion
Email: heloisa.perista@cesis.org
Maria de Lourdes Quaresma (Centro de Estudos para a Intervenção Social - CESIS)
Expert in Long-term care and Pensions
Email: mlurdes.quaresma@gmail.com
National coordination: Pedro Perista
ROMANIA
Dana Otilia Farcasanu (Foundation Centre for Health Policies and Services)
Expert in Healthcare
Email: dfarcasanu@cpss.ro
Luana Pop (Faculty of Sociology and Social Work, University of Bucharest)
Expert in Long-term care and Social inclusion
Email: Luana.pop@gmail.com
Daniela Urse (Pescaru) (Faculty of Sociology and Social Work, University of
Bucharest)
Expert in Pensions
Email: daniela_pescaru@yahoo.com
National coordination: Luana Pop
SERBIA
Jurij Bajec (Faculty of Economics)
Expert in Pensions and Social inclusion
Email: jbajec@ekof.bg.ec.ra
Ljiljana Stokić Pejin (Economics Institute Belgrade)
Expert in Healthcare, Long-term care and Social inclusion
Email: ljiljana.pejin@ecinst.org.rs
National coordination: Ljiljana Stokić Pejin

Inequalities in access to healthcare A study of national policies
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SLOVAKIA
Rastislav Bednárik (Institute for Labour and Family Research)
Expert in Long-term care and Pensions
Email: Rastislav.Bednarik@ivpr.gov.sk
Andrea Madarasová Gecková (P.J. Safarik University in Kosice)
Expert in Healthcare and Long-term care
Email: andrea.geckova@upjs.sk
Daniel Gerbery (Comenius University)
Expert in Social inclusion
Email: daniel.gerbery@gmail.com
National coordination: Daniel Gerbery
SLOVENIA
Boris Majcen (Institute for Economic Research)
Expert in Pensions
Email: majcenb@ier.si
Valentina Prevolnik Rupel (Institute for Economic Research)
Expert in Healthcare and Long-term care
Email: rupelv@ier.si
Nada Stropnik (Institute for Economic Research)
Expert in Social inclusion
Email: stropnikn@ier.si
National coordination: Nada Stropnik
SPAIN
Ana Arriba Gonzáles de Durana (University of Alcalá)
Expert in Social inclusion
Email: ana.arriba@uah.es
Francisco Javier Moreno Fuentes (IPP-CSIC)
Expert in Healthcare
Email: javier.moreno@cchs.csic.es
Vicente Marbán Gallego (University of Alcalá)
Expert in Long-term care
Email: vicente.marban@uah.es
Julia Montserrat Codorniu (Centre of Social Policy Studies)
Expert in Long-term care and Pensions
Email: jmontserratc@gmail.com
Gregorio Rodríguez Cabrero (University of Alcalá)
Expert in Long-term care, Pensions and Social inclusion
Email: gregorio.rodriguez@uah.es
National coordination: Gregorio Rodríguez Cabrero

Inequalities in access to healthcare A study of national policies
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SWEDEN
Johan Fritzell (Stockholm University and Karolinska Institutet)
Expert in Healthcare and Social inclusion
Email: johan.fritzell@ki.se
Kenneth Nelson (Stockholm University)
Expert in Social inclusion
Email: kennethn@sofi.su.se
Joakim Palme (Uppsala University)
Expert in Pensions
Email: Joakim.Palme@statsvet.uu.se
Pär Schön (Stockholm University and Karolinska Institutet)
Expert in Long-term care
Email: par.schon@ki.se
National coordination: Johan Fritzell
SWITZERLAND
Giuliano Bonoli (Institut de Hautes Etudes en Administration Publique - IDHEAP)
Expert in Pensions and Social inclusion
Email: giuliano.bonoli@unil.ch
Philipp Trein (University of Lausanne)
Expert in Healthcare and Long-term care
Email: josephphilipp.trein@unil.ch
National coordination: Giuliano Bonoli
TURKEY
Fikret Adaman (Bogazici University)
Expert in Healthcare and Social inclusion
Email: adaman@boun.edu.tr
Dilek Aslan (Hacettepe University)
Expert in Long-term care
Email: diaslan@hacettepe.edu.tr
Bekir Burcay Erus (Bogazici University)
Expert in Healthcare and Social inclusion
Email: burcay.erus@boun.edu.tr
Serdar Sayan (TOBB Economics and Technology University)
Expert in Pensions
Email: serdar.sayan@etu.edu.tr
National coordination: Fikret Adaman
UNITED KINGDOM
Fran Bennett (University of Oxford)
Expert in Social inclusion
Email: fran.bennett@dsl.pipex.com; fran.bennett@spi.ox.ac.uk
Jonathan Bradshaw (University of York)
Expert in Pensions and Social inclusion
Email: Jonathan.bradshaw@york.ac.uk
Caroline Glendinning (University of York)
Expert in Long-term care
Email: caroline.glendinning@york.ac.uk
National coordination: Jonathan Bradshaw

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Access to social protection for people working on non-standard contracts and as self-employed in Europe – A study of
national policies
doi: 10.2767/3714080.2767/978434
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