Across the United States of America and Europe, consumer satisfaction is playing an increasingly important role in quality of care reforms and health-care delivery more generally. However, consumer satisfaction studies are challenged by the lack of a universally accepted definition or measure (1-6) and by a dual focus: while some researchers focus on patient satisfaction with the quality and type of health-care services received, (7-10) others focus on people's satisfaction with the health system more generally. (11-14) The importance of both perspectives has been demonstrated in the literature. For example, satisfied patients are more likely to complete treatment regimens and to be compliant and cooperative. (14,15) Research on health system satisfaction, which is largely comparative, has identified ways to improve health, reduce costs and implement reform. (16)
The absence of a solid conceptual basis and consistent measurement tool for consumer satisfaction has led, over the past 10 years, to a proliferation of surveys that focus exclusively on patient experience, i.e. aspects of the care experience such as waiting times, the quality of basic amenities, and communication with health-care providers, all of which help identify tangible priorities for quality improvement. In the future, measures of patient experience, intended to capture the "responsiveness" of the health system, (17) a concept developed by WHO, are likely to receive even greater attention as physicians and hospitals come under growing pressure to improve the quality of care, enhance patient safety and lower the cost of services. Health system responsiveness specifically refers to the manner and environment in which people are treated when they seek health care.
The increasing importance of patient experience and the sustained interest in comparing people's satisfaction with the health system across different countries and time periods suggests the need to characterize the relationship between them. Research relating global satisfaction ratings with patient experience has revealed strong associations between the two. (18) Yet, to what extent patient experience explains satisfaction with the health-care system remains unclear. The literature suggests that much of the remaining variation in health system satisfaction after adjusting for factors commonly used to measure the concept is a reflection of patient experience. (19,20) We disagree and hypothesize that patient experience accounts for only a small fraction of the unexplained variation in health system satisfaction, even after adjustments for the demographic, health and institutional factors with which such satisfaction is commonly associated. (16-18,21-24) In particular, we expect most of the variation in satisfaction with the health-care system to be explained by factors above and beyond patient experience.
In this paper, we explore the factors underlying people's degree of satisfaction with the health-care system and the extent to which the latter reflects their experience of care. Data from the module on health system responsiveness in the World Health Survey for 2003 (25) provided a unique opportunity to better understand the determinants of people's satisfaction with the health-care system, besides their experience as patients, in 21 countries of the European Union (EU). Throughout the paper, we use WHO'S term "responsiveness" to refer to satisfaction with the health system from the perspective of patient experience.
The conceptual basis and design of the responsiveness module in the World Health Survey have been described extensively in the literature. (22,24) This paper presents results from the responsiveness module of the World Health Survey that was fielded in 71 countries in 2002 and 2003 (the survey instrument is available at: http://www.who.int/ healthinfo/survey/whslongindividuala. pdf). This paper focuses on the EU, given the similarity in health outcomes among its member countries (26) and the relevance of consumer satisfaction to quality of care reforms in that region. …