The health care systems of the European Union (EU) member states have been subject to continuous reform over the last twenty years, mainly stemming from the pressures of aging populations and challenges in reforming public budgets. Over the same period, the EU witnessed its biggest enlargement (the so called big bang) that brought in ten new countries – almost all of which belong to the group of ‘transition’ countries. The enlargement in 2004 (and the subsequent one in 2007)a also allowed for the possibility of both patients and medical staff to migrate across borders, thus adding further layers of complexity to the extant national health care systems. Given this background, an evaluation of people’s perception of health care quality (and of patient safety) is a high-priority task, not least because a careful examination of factors that influence perceptions of health care quality could provide the basis for effective policy action aimed at improving access to services and the quality of national health care. Having said that, evaluating the quality of health care is not a new topic. Indeed, to date, there have been many systematic cross-country reviews (and subsequent ranking) of health care systems. Some of them have tried to understand the quality of national health care from a comparative perspective, while others (relying on surveys of patient satisfaction/perception of quality) help to provide a deeper understanding of the determinants of health care quality at national level.
Using the Eurobarometer 327 (2009) survey, we look at the general population’s perception of health care quality and patient safety in a cross-country EU setting. This paper adds to the extant literature in three crucial ways: (i) we study the macro-level and socio-demographic determinants of the general population’s perception of the quality of healthcare; (ii) building on (i), we disentangle which aspects of health care are the most important in shaping the perception of health care quality; and (iii) we analytically explore the macro-level and socio-demographic determinants of the likelihood of being harmed by medical procedures. While doing so, we employ additional robustness checks. It is important to note that there are two limitations to our findings: the lack of control variables vis-à-vis personal-level health care utilisation rates and subjective health evaluations. We have addressed these shortcomings by using macro-proxy variables for health care utilisation (health care expenditure as a percentage of gross domestic product (GDP)) as well as controlling for age, which is usually strongly correlated with subjective health status evaluation.
A substantial literature focuses on the issue of quality of health care (both qualitative and quantitative). The existing qualitative body of research can be divided into two main groups, one relying on medical professionals’ perceptions of quality (see, for example, Robinson et al ) and the other solely focusing on patientsb. Patient surveys could offer a better overview of perception of health care quality and safety . According to the authors, evidence shows that patient perceptions are distinctive, and often conflicting, compared with those of the health care providers, which ultimately leads to different assessments of health care quality. Given that patients are the final users of health care services, considering their perceptions would be more important. Furthermore, most of the studies using patient surveys are small-scale studies that use patient interviews and focus groups (Anderson et al , Attree , Concato and Feinstein , Gerteis et al , Irurita , Jun et al , Larrabee and Bolden , Ngo-Metzger et al , Radwin , Stichler and Weiss , and Ware and Stewart ). Finally, within the body of research that focuses on patients, a sub-section concentrates on patient satisfaction with health care services as the only measure of health care quality (Taylor and Cronin , Babakus and Mangold , Sohail ). However, this subsection of literature has been fairly controversial and has received significant criticism from the research community (for a detailed discussion , see Crow et al ).
Another strand of literature has looked at perceptions of quality of health care from a quantitative and cross-country perspective. To date, there have been two papers that have looked at the issue of patient quality from this perspective. Cleary et al  analysed the quality of health care using patient-reported measures of quality in the United States, Australia, Canada, New Zealand and the United Kingdom. Wendt et al  used a truncated sample of 14 EU countries to assess the preferences for state involvement, and subsequently, quality of health care across the EU.
In addition, a significant body of literature has looked at the determinants of what constitutes the core attributes of health service quality. Gronroos  argues that these attributes can be divided into two groups: functional (ambience, i.e. description of the form in which the service is delivered) and technical (outcome, i.e. the quality of what is delivered). Similar reasoning is found in other studies on the topic (Zifko-Baliga and Krampf , DeRuyter and Wetzels ).
To the best of our knowledge, there is one study concerning patient safety in a cross-country setting, assessing the likelihood of medication and medical errors in five OECD countries (Cleary et al ). Finally, in the context of the US, a burgeoning literature has looked at various aspects of quality and performance of HMOs (Health Maintenance Organisation). The overall finding of that sizeable literature points to a negative link between age and perception of quality as well as a negative link between chronic illness and perception of quality (Miller and Luft [23, 24],).
Following the strands of literature outlined above, in this paper we answer the following three questions:
What individual and macro-level variables drive the perception of quality of healthcare among EU nationals?;
What attributes of healthcare play the biggest role when evaluating the quality of healthcare?;
What individual and macro-level variables drive the perception of the likelihood of being harmed by hospital or non-hospital care?