Attempts at best medicine rankings prove a bitter pill
Sunday, 13 July 2008
Nicholas Timmins, Clive Cookson and Andrew Jack
It is a beguilingly simple question: which is the best health system in the world? But although it is often asked, there is no sensible single answer.
Indeed, trying to answer it has proved destabilising for researchers. When the World Health Organisation (WHO) attempted it in 2000 - putting France top, the UK 18th and the US 37th alongside Cuba - the effort proved so provocative that it undermined several of the agency's senior officials, who have since left. The exercise has never been repeated.
Policymakers and health economists tend to rank health systems by quality, usually defined by about half a dozen measures, such as how equitable is the system? How efficient? How easy to access? How good are the results?
The problem comes in deciding what weight to attach to each factor. The answer will vary depending not only on social and political outlook but also on the role played by the respondent: whether that of citizen, taxpayer or patient.
Someone from the traditional right - a US Republican, say - is likely to rate choice and rapid access to care more highly than equity. A Democrat is likely to rate equity and efficiency over access and choice.
As citizens, however, right wingers might still care deeply about access for the less well off, while those on the left can still balk at the tax bills an inefficient system generates. Once people become patients, moreover, they are generally blind to the cost their treatment imposes on others - whether the "others" are taxpayers or people covered by the same insurer, regardless of whether theirs is a public or private scheme.
Comparison is also dogged by the difficulty of assembling reliable data, Martin McKee of the European Observatory on health systems says. Boundaries between health and social care vary widely between countries; definitions and measures that sound the same turn out to be different.
Short of conducting a poll of health economists, it is hard to know which they would choose if forced to select "the best". But it is a fair guess that many would put Sweden, France or the Netherlands at or near the top of their lists. Their admiration would be undimmed by Sweden's waiting lists; the relatively high costs and positively dangerous level of drug consumption that marks the French system; and the Netherlands' failure to top the table on all measures of successful treatment. Some are fascinated by Singapore, and Switzerland while Japan used to be fashionable.
But because all health systems mutate, and ways of measuring them improve and shift, their answers even a decade ago would probably have been different.
As for individuals, innate selfishness dictates that the answer depends on one's circumstances. People with high quality health insurance who do not have to contribute much towards their care - living in California, Miami or on the north-east coast of the US, for example - might well pick their own country. A low-paid first generation British citizen, living in a big city and suffering from a chronic condition such as asthma, might even choose the UK - if, that is, he is lucky enough to have a high class general practice around the corner.
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FT Syndication Service
It is a beguilingly simple question: which is the best health system in the world? But although it is often asked, there is no sensible single answer.
Indeed, trying to answer it has proved destabilising for researchers. When the World Health Organisation (WHO) attempted it in 2000 - putting France top, the UK 18th and the US 37th alongside Cuba - the effort proved so provocative that it undermined several of the agency's senior officials, who have since left. The exercise has never been repeated.
Policymakers and health economists tend to rank health systems by quality, usually defined by about half a dozen measures, such as how equitable is the system? How efficient? How easy to access? How good are the results?
The problem comes in deciding what weight to attach to each factor. The answer will vary depending not only on social and political outlook but also on the role played by the respondent: whether that of citizen, taxpayer or patient.
Someone from the traditional right - a US Republican, say - is likely to rate choice and rapid access to care more highly than equity. A Democrat is likely to rate equity and efficiency over access and choice.
As citizens, however, right wingers might still care deeply about access for the less well off, while those on the left can still balk at the tax bills an inefficient system generates. Once people become patients, moreover, they are generally blind to the cost their treatment imposes on others - whether the "others" are taxpayers or people covered by the same insurer, regardless of whether theirs is a public or private scheme.
Comparison is also dogged by the difficulty of assembling reliable data, Martin McKee of the European Observatory on health systems says. Boundaries between health and social care vary widely between countries; definitions and measures that sound the same turn out to be different.
Short of conducting a poll of health economists, it is hard to know which they would choose if forced to select "the best". But it is a fair guess that many would put Sweden, France or the Netherlands at or near the top of their lists. Their admiration would be undimmed by Sweden's waiting lists; the relatively high costs and positively dangerous level of drug consumption that marks the French system; and the Netherlands' failure to top the table on all measures of successful treatment. Some are fascinated by Singapore, and Switzerland while Japan used to be fashionable.
But because all health systems mutate, and ways of measuring them improve and shift, their answers even a decade ago would probably have been different.
As for individuals, innate selfishness dictates that the answer depends on one's circumstances. People with high quality health insurance who do not have to contribute much towards their care - living in California, Miami or on the north-east coast of the US, for example - might well pick their own country. A low-paid first generation British citizen, living in a big city and suffering from a chronic condition such as asthma, might even choose the UK - if, that is, he is lucky enough to have a high class general practice around the corner.
.........................................
FT Syndication Service