The best and worst health systems

This morning I came across a link in my Twitter feed about the best and worst health systems in the world.  On closer inspection it was referring to the Commonwealth Fund’s study from last year comparing the performance of the US’s health system to ten other developed country health systems.  If you missed the reporting at the time the summary is copied below and you can read the full report here.

For those who hear little but how bad the UK National Health Service is, the results might be surprising given that this health system comes out on top.  The UK scores particularly well on access, quality of care, efficiency and equity for an average health expenditure per capita of $3,405 (US$).  The only area that the UK does not do well is in terms of the score for ‘Health Lives’ which is a score based on mortality amenable to medical care, infant mortality and healthy life expectancy at age 60.

France’s ranking was a bit of a surprise for me in this study.  From comparative research I’ve read before I expected that France would do pretty well but it comes 9th out of 11 countries .  Sure the health expenditure per capita is a bit more than some other countries ($4,118) and we know that the French system isn’t the most efficient but I was surprised to see it come bottom in terms of access and close to bottom on quality care and equity.  France does top the chart in one area though – healthy lives.

I always think these rankings of health systems are fascinating, particularly because they are a very visible trade off between a range of different factors.  This sort of analysis typically tends to show that unless you live in Sweden and enjoy paying high taxes, you can’t have it all.  Typically it is argued that the UK NHS trades off the kinds of access you get in other systems (being able to get an appointment with your GP within a week, for example, or going directly to a specialist) for efficiency gains.  Any economist will tell you that having a queue and a gatekeeper for specialist services are helpful in driving efficiency.  In this study the UK does well on access, which I assume is because access is considered to be a measure of both timeliness of care and also cost associated with accessing health care.  As a universal system free at the point of use the UK was always going to do well on those sorts of metrics.

What these figures don’t seem to reflect though is the fact that the UK is four quite different health systems now with political devolution to Scotland and Wales in the late 1990s and Northern Ireland has always operated slightly different due to political factors (for those interested in this natural experiment see some of Scott Greer’s work).  We are starting to see interesting trends in the data that come from these devolved nations in comparison with England and questions being asked about the degree to which these are linked to organisation and management reforms.

The US comes dead last in the list, low down on pretty much all of the metrics at an average health cost per capita of $8,508 – and yet internationally is often known as being at the forefront of medical research.  Some of the best care may be available, but it is not necessarily widely shared as the US does very badly on equity.  It will be interesting to see the impact that the Affordable Care Act makes on these figures over time.

The only saving grace for the US might be Canada’s poor showing in these rankings.  They came overall second to bottom at a health expenditure per capita of $4,522 and poor on quality care, access, efficiency, equity and a low placing on healthy lives.

For the Aussies out there you will be pleased to hear you score 4th, doing particularly well on quality of care and for a cost per capita of about $3,800.  Interestingly Australia doesn’t do too well in terms of access, which was a shock to me given that on moving to Australia for the first time ever in my life I got an appointment with a GP on the same day that I wanted one and it was on a weekend.  The report cites cost-related problems with the Australian system which presumably is the result of the dual public and private systems.

The thing that really stands out in these figures is the relationship between healthy lives and health systems.  If the UK systems ranks first on all things but healthy lives and the French system ranks low on most things but first on healthy lives then what is going on here?  Are we saying that health systems have no bearing on health outcomes?  The more right wing amongst you might be thinking this is an example of how a ‘Socialist nanny state’ like the UK doesn’t encourage people to look after their health (although I would of course point out that the US comes rock bottom on healthy lives and Sweden comes 2nd in this category and first in terms of equity).  Or is the issue that indicators like ‘healthy lives’ are more long term and we might expect the recent improvements made in the NHS will filter through to improve these aspects in ten or twenty years time?

Of course there are no easy answers to these sorts of questions but comparing systems in this way is a fascinating way to get into discussions about both the relative merits of different approaches to organising and delivering services and also what we want from our health systems.  In the mean time this is a nice change from just reading bad things about the UK NHS.

commonwealth fund


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