Ranking healthcare systems worldwide

Does France provide the world’s best health service? How is a good healthcare system defined? Who decides that one healthcare system is better than another? What do we expect from a healthcare system? The answers depend on your perspective, says EH Paris Correspondent Jane MacDougall

Photo: Ranking healthcare systems worldwide
Photo: Ranking healthcare systems worldwide

The World Health Organisation (WHO) last ranked worldwide healthcare systems based on 1997 data in its World Health Report Health Systems: Improving Performance published in 2000. Over a decade ago and still this report is being debated and discussed the world over as politicians and policy makers try to create sustainable and effective healthcare systems for their countries.

The WHO's assessment was based on five indicators. On these criteria, France was ranked best ‘overall healthcare’ in the world. Is this really a true reflection of healthcare in the world and France in particular? What does France have in each of these categories that make its healthcare so good?

Population health was the first criterion measured, because health is, after all, the defining objective for any health system. To assess the overall health of a population, WHO chose to use disability-adjusted life expectancy (DALE), which is directly comparable to life expectancy estimated from mortality alone and can be readily compared across populations.

At the time of the WHO study France’s life expectancy was 3rd highest in the world. Today, at 81 years, it is the 10th highest by 2011 estimates in the CIA World Factbook.

The second criterion measured was health inequality. Within the population a health system ideally should protect the ill and infirm from financial risk. Since Lionel Jospin’s government introduced ‘universal health coverage’ in 2000, health cover has been extended to everyone legally resident in France, regardless of employment or income.
An important element of the French insurance system is solidarity: the more ill a person becomes, the less they pay. This means that for people with serious or chronic illnesses (e.g. cancer, AIDS, diabetes or severe mental illness etc.), the insurance system reimburses them 100 % of expenses and there are no co-payment charges. However, although access to GPs is equally accessible for both rich and poor in France, a recent report has shown that there is an uneven distribution of care at specialist level with higher-income groups having greater access to this level of care (Thomson and Mossialos. Primary Care and Prescription Drugs: Coverage, Cost-Sharing, and Financial Protection in Six European Countries. Commonwealth Fund Pub. 1384 Vol. 82). However, in every country except the UK, higher-income groups use specialists at higher rates, which may reflect both higher cost-sharing for specialist visits and an uneven distribution of specialists in other European countries.

Overall level of responsiveness was the third factor examined. Responsiveness is a measure of the ‘human face’ of the healthcare provided, whether or not it meets the populations’ expectations of how they should be treated, in terms of attitude of healthcare providers, quality of services, choice of provider and waiting times.

A survey of nearly two thousand key informants in selected countries was used to assess the level of responsiveness in 200 countries while, in others, indirect methods were used. In terms of level of responsiveness the USA was ranked highest with France only 16th, behind many other European countries including, Germany, Denmark and Switzerland. It ranked much higher though for the distribution of responsiveness -- the fourth factor considered. This was determined by asking the interviewees for the survey whether they could identify groups that were frequently excluded from healthcare. Four groups were often mentioned; poor people, women, old people and indigenous groups or racial minorities.
The final factor taken into account was fairness of financial contribution.

The health system in France is largely financed by the government. In 2005, France spent 11.2% of GDP on healthcare; this is more than most European countries. However, per capita at approximately € 2,439, it is roughly similar to spending in Germany, the Netherlands, Denmark and Sweden.

Due to criticisms of its methodology and the difficulty of producing such a report, WHO has not entered into another comparison of world healthcare systems.

So did France really have a better overall health system and does it still, ten years on?
On a personal note, as a user of the system for the past 20 years all I can say is that it has never let me or my family down but does make it the best?


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