The mirror on the wall

Charlotte Haug About the author

Comparisons and rankings are fun – especially when one emerges with flying colours

Photo: Einar Nilsen

Norway has been ranked as the best country in the world in which to live for many years in succession, because we score highest on the UN Human Development Index – HDI. The index is calculated according to a formula which includes life expectancy, education and income and this is intended to give an indication of a country’s social development. It was developed in 1990 by the Pakistani economist Mahbub ul Haq and the Indian economist Amartya Sen and is published by the United Nations Development Programme – UNDP. We are quite understandably proud of this ranking, and the index is used in a number of relatively official contexts, for example when the Directorate of Health presents its key figures for the health services (1) or when the President of The Norwegian Confederation of Trade Unions (LO), Gerd Kristiansen, states that: «In short, a strong union movement helps to give us the society that tops the UN Human Development Index year after year» (2).

We do not do quite so well in other comparisons. On 17 June 2014 the Commonwealth Fund published a ranking of the health services in 11 different countries – and the Norwegian health services came out of it quite badly (3). The report was not covered to any great degree by the Norwegian media, and received a very negative response from the Norwegian Knowledge Centre for the Health Services: «The Knowledge Centre is sceptical of the new ranking that the American foundation The Commonwealth Fund has recently given the health services in various countries. Ranking should be avoided due to the number of random and systematic measurement errors,» they wrote on their website as early as 20 June. (4). The British health authorities were less sceptical of the ranking and the methods used (5), and so was the BMJ (6). This was possibly due to the fact that the UK health services were awarded first place.

Is there any reason to give credence to this study, or should we simply brush it aside? The Commonwealth Fund is a private American foundation that aims to «promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable.» The foundation provides funding for independent health service research. Karen Davis, the first author of the report, is a professor at the Department of Health Policy and Management and director of the Center for Integrated Health Care at Johns Hopkins University, USA. The study has been conducted four times previously, but this is the first time that Norway has been included. There was to be an optimal basis for performing a sound analysis. The data used came from surveys of patients, doctors and the general population which the foundation has conducted in all the countries under comparison. They are supplemented by data from the World Health Organization (WHO) and the Organisation for Economic Co-operation and Development (OECD).

Based on these data, a calculation was made of the quality, access, efficiency and equity of the health services in the various countries, in addition to what they term «healthy lives.» Quality is defined in this study as health services that are efficient, safe, coordinated and patient-centred. Good access means that the health services are not too costly and that patients are seen without unnecessary waiting times. Efficiency is defined as follows: «An efficient, high-value health care system seeks to maximize the quality of care and outcomes given the resources committed.» Equity means that treatment and care do not vary in quality based on gender, ethnicity or socioeconomic status. In order to calculate «healthy lives» the authors looked at mortality connected with the health service (i.e. mortality that might have been avoided with the right treatment at the right time), infant mortality and life expectancy. These are definitions and indicators that appear sensible and relevant. The article explains the methodology in detail (3). For Norway the main findings were depressing: We were the poorest of all the countries on quality, we were below average on access, equity and expectation of healthy lives, and slightly above average on efficiency.

«Whatever standards we apply, it is evident that health systems in some countries perform well, while others perform poorly. This is not due just to differences in income or expenditure: we know that performance can vary markedly, even in countries with very similar levels of health spending. The difference between a well-performing health system and one that is failing can be measured in death, disability, impoverishment, humiliation and despair,» wrote the then Director General of the WHO, Gro Harlem Brundtland in the foreword to the World Health Report in 2000 (7). The report was an ambitious and comprehensive attempt to discover exactly what worked and what did not work in the health services of various countries – with a view to using these results to prioritise and improve. However, instead of it being used in this manner, there was so much discussion about methodology and criteria that the WHO quite simply ceased to attempt to rank the health services of different countries.

Neither is it difficult, of course, to find weaknesses in a study such as the one conducted by the Commonwealth Fund, and the authors themselves point this out. Naturally the main objection is that it is based on the opinions that patients, next of kin and doctors have about the health service rather than on «hard data» about patients and treatment results. Clearly we would like to have this type of data. It is almost incredible that those who own and run such a gigantic, important and risk-filled enterprise as the health service – in Norway, the state and the municipalities – do not have this overview. While we await better data, however, there is good reason to take a look in the mirror and ask ourselves whether Norwegian patients do not deserve a health service that is perceived as being on a par with the health services of countries we normally compare ourselves to.

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