Beyond the Public-Private Debate:an examination of quality, access and cost in the health-care systems of eight countries

excerpts from an informative study..click the link in the title to access the full study...rw

There are both indicators of health (outcome measures) and determinants of health. Mortality data - life expectancy, standardized mortality, infant mortality, maternal mortality and years of potential life lost - have been the main measures of the health status of a population. As life expectancy and the prevalence of chronic disease has been increasing, there has been a need for other indicators that measure the quality of life; indicators that measure self-perceived health, physical disability, mental functioning, etc.47


The decision of how to rank country performance is based on the paradigm of what should constitute a health-care system's principles when trying to achieve better health status for a population: high quality care, broad access to care and low costs.
Quality of care is measured using the categories of health status, mortality rates, preventable illnesses, appropriateness of services and patient satisfaction. Access to care takes into account the amount of insurance coverage in a population, equity in health outcomes, how health spending is distributed between acute and other health services, the availability of medical expertise and technology. Cost comprises efficiency, total health spending and sustainability.

...Singapore has the "best" health-care system of the eight countries, with a score of 62.1. In terms of the overall health-system score, the United Kingdom ranks second (60.5), Switzerland third (59.2), followed by Germany (59.0), Australia (56.8), Canada (56.7), the United States (53.6) and South Africa (45.4).

Quality of care
The health of a population is due, in part, to the quality of a country's health-care system. The safe birth of a child, the public's awareness of what constitutes healthy eating and living, and the incidence of treatable diseases all relate to how well a health system is performing.
Canada ranks first in health status. This category includes life expectancy, healthy life expectancy (years lived free-of-disability), the percent of population not expected to survive to age 40, self-reported health status, and the prevalence of smoking, alcohol consumption and obesity in the population. (My note: the US rates Fifth of eight, behind Switzerland, Canada, Singapore, and Germany in health status indicators. Tell me again how the US has the best healthcare system in the world? read on, we cant even claim the highest rating for Technology or satisfaction with all our options...)

Switzerland has the highest patient satisfaction, due to short waiting times for non-emergency treatment and to a high system-responsiveness ranking ...

Access to care
In Switzerland, health insurance is mandatory and, in Canada, the United Kingdom and Australia, every citizen is eligible for health insurance provided by the public sector. These countries, therefore, rank highly in terms of health coverage.

With respect to the availability of health-care resources, Germany ranks first, scoring 76.6 for service availability. Germany has more hospital beds per capita, and more physicians, specialists and dentists per 1,000 population than any of the other countries. While Switzerland does not have the most computed tomography (CT) scans per million people or the most magnetic resonance imagers (MRIs) per million population - it comes second to Australia in CT scans and second to the United States with respect to MRIs - it manages to attain the top ranking in the technology category with a score of 88.3.

Cost Of Care
While there is some debate as to whether high health-care spending is positive or negative, the traditional perspective is that health costs must be contained. Therefore, this study assumes that more spending on health is worse than less. Thus, both Singapore (94.7) and South Africa (87.4) rank highly while the United States scores the lowest on every indicator and receives a score of zero for this category. Germany, another big spender on health, scores a 34.6.
The sustainability of a health-care system is dependent on whether a country can afford to maintain it. The aging population is going to put a stress on every health-care system, thus the projected percent of the population over 65 years old and the amount spent on them relative to the rest of the population are included in this category. Sustainability also includes the number of medical students per million population, total expenditure on research and development (R&D), and the number of R&D scientists and technicians per 1,000 population.
Switzerland, with a score of 54.9, is in the most favorable position regarding the future of its health-care system; the United States and Australia, both at 35.7, the worst.

WHO's report ... that there is evidence that health systems do little to improve health: studies have shown life expectancy to be correlated with income per capita but not to the numbers of doctors, hospital beds or health expenditure.
As well, in the United States alone, medical errors kill some 44,000 people in hospitals annually.50 And, WHO notes that, while "rich" people tend to benefit more from the use of hospital and primary care services, "the distribution of primary care is almost always more beneficial to the poor than hospital care…."51

As with most studies of this nature, the main conclusion is that more data and a higher quality of data are needed. Areas for which data are lacking include the numbers and types of hospital procedures being performed; who is being treated, for what and how promptly;
The list is almost endless.
A well-defined set of performance indicators would help policymakers, funders and health managers in the management of health-care systems and policy development. It would help patients better monitor the quality of the system into which their tax dollars are going and from which they must receive their health care.