Healthcare systems are complex, enormous and unwieldy, whether they are state-managed monoliths such as the UK’s, or dominated by the private insurance sector, as in the US. They are traditionally slow to adapt to change, but now those immovable objects are being forced to confront not just one, but several irresistible forces: demographic (ageing populations), epidemiological (increasing incidence of chronic diseases), technological (more expensive drugs and technologies) and economic (global recession, high public debt, smaller pensions). The price for ignoring these forces could be disastrous— the US president, Barack Obama, has warned that if it is allowed to continue down its present course, the US healthcare system will bankrupt the entire country.

Try telling the end-users of healthcare about these pressures, and they will be nonplussed. In a major survey for this report, the Economist Intelligence Unit set out to ascertain just what the citizens in four large economies—the US, UK, Germany and India—think about their healthcare systems. The findings show clearly the kinds of dilemmas faced by healthcare policymakers who seek to implement reforms.

The starkest example emerges when respondents were asked in basic terms about their expectations for choice and cost in healthcare. Globally, 83% of respondents say that they would prefer to shop between a range of options in order to get the best treatment. At the same time, however, more than half say that they are not prepared to pay more to get a better healthcare service, whether in the form of taxes, fees at point of provision or fees to insurers. Consumers want choice—but are not prepared to pay for it.

Our survey shows that citizens’ expectations for healthcare are high—not just in developed countries, which have been used to high standards of care, but also in developing countries such as India, where people are becoming accustomed to better standards. They want access to the latest treatments, timely, affordable care, and a range of choices. They are better informed than ever about their health and their treatment options. They are prepared to take some responsibility for their own health, but broadly they do not want to have to pay a lot more than they already are for their healthcare. If they are unhappy with aspects of their healthcare, they largely lay responsibility at the feet of their governments.

Key findings from the survey include the following:

• Governments get a thumbs-down on their handling of healthcare. Not surprisingly, the economy and jobs are seen by respondents as the most important issues for their government, but healthcare takes second billing in the US, Germany and India—ahead of education, the environment, crime, defence and housing. In the UK it comes third, after crime, but 29% of Britons are generally more inclined to agree that their government has the right approach to healthcare. By contrast, just 8% of Germans think their country is on the right track, whereas 62% think their government has the wrong approach, as do nearly half of American respondents.
• If patients are now customers, they are not happy ones. When it comes to healthcare, Americans,arguably, have more choices than citizens of most other countries. However, when asked to indicate their levels of satisfaction with a range of aspects of healthcare (such as waiting times, quality and availability of care and doctors, cost of treatment and medicine), almost one-quarter of Americans say they are not satisfied with any. That was an even higher figure than in the UK (15%), where patients have far less choice. That does not mean Americans believe they receive poor-quality care—compared with other countries, more US respondents are satisfied with the quality of their doctors, with waiting times and with general quality and availability of healthcare—but the finding does indicate a high level of general dissatisfaction. Strikingly, about one in five respondents across the global sample say they are not satisfied with any aspect of their country’s healthcare system.
• Some patients are more empowered than others. Only one-quarter of UK respondents feel they have much control and influence over where and how they are treated, compared with 64% of Americans. Nearly 60% of British respondents say that they are not encouraged to choose from a range of doctors or hospitals for their treatment. The UK government’s recent about-face, allowing patients to choose between public and private healthcare, without losing access to the National Health Service (NHS), appears to be a welcome one—three out of four respondents say that they would compare services to get the best possible treatment. Meanwhile, US residents are more optimistic (74%) than those in the UK (61%) or Germany (38%) that they will get prompt, effective treatment if they become ill. Some 74% of Americans, however, say they are concerned about being able to afford that treatment—far more than Germans (55%) or Britons (50%).
• Britons are not keen on fees, but are more relaxed about tax. UK citizens are less keen than people elsewhere on the idea of paying fees at the point of provision (co-payments), or to insurers, for an improved healthcare service. However, the survey found that more Britons (27%) would be willing to pay higher taxes for improved healthcare services than would Americans (15%) or Germans (9%). Meanwhile, nearly 45% of Britons say that they would not be willing to pay anything extra, compared with 61% of Americans and 64% of Germans. The British are also wary of the notion that greater private-sector involvement would improve the country’s healthcare system, perhaps not surprising given that private healthcare takes up a relatively small amount of the country’s healthcare expenditure.
• German gloom spells a warning to reformers. Germany began reforming its healthcare system a decade ago. Since then, according to Economist Intelligence Unit data, Germans are living longer and pay less for their healthcare than many of their neighbours. However, German citizens’ doubts about their healthcare system permeate the survey, just as German healthcare professionals revealed their pessimism in a separate Economist Intelligence Unit survey earlier this year. Far fewer German citizens (38%) than those elsewhere are optimistic that they will get prompt, effective treatment, more than half are worried about the costs of getting treatment, and far more (79%, compared with 57% in the UK and 36% in the US) feel their healthcare professionals are working too many hours to be effective.

In search of the grand bargain
Against all this, policymakers are floundering to come up with solutions. They need to find a way to strike a grand bargain with patients, who are no longer simply passive recipients of care, but increasingly active consumers of health services.

The key issue is not necessarily one of knowing which reforms to implement. No matter how sensible reform plans may sound, there is generally one important stakeholder who remains unconvinced: citizens. There is a big gap between policymakers and consumers when it comes to appetite for health reform. The first group sees it as an essential way to relieve financial and social pressures, while the second is afraid that they might lose what they currently have. Consequently, selling healthcare reform is not a task for the faint-hearted. Even Mr Obama, who campaigned successfully on the issue in his presidential campaign, has struggled in his bid to implement a fairer system in the US. The example of Germany— which implemented major reforms a decade ago, but whose citizens remain broadly pessimistic about their healthcare and distrustful of those who manage it—serves as a warning to would-be reformers.

If they are to be successful, policymakers must be prepared to be thick-skinned and patient, and to avoid quick fixes. The results of broad-based reforms are unlikely to be seen overnight: South Korea’s plan to introduce universal healthcare coverage began in 1977, and is still being developed today. The UK has pumped millions of extra pounds into its NHS in the last decade, but it may be that the country’s more subtle reform strategies, such as patient-reported outcome measures, will be the ones that have most impact on cost containment and patient satisfaction in the long term.