Evaluating Global Health Systems

Ezekiel Emanuel likes to rank things. Everything, that is, but health care systems. As one of the premiere health policy experts in the US and an architect of the Affordable Care Act, however, he is often asked to provide just such a ranking. Given the complexity of health care, his reluctance to do so is hardly surprising. In his new book, Which Country Has The World’s Best Health Care?, his response to such complexity is to provide an extensive analysis of health care financing and delivery in eleven countries. He divides the analysis into five domains: coverage, financing, payment, delivery, and pharmacy prices. Although this approach does not enable him to provide an overall ranking of global health systems, it does inform a performance evaluation provided at the end of the book. Not surprisingly, the US is identified as a poor performer in coverage because of the lack of universal coverage. Other shortcomings of the US health system include complex payment systems and drug pricing mechanisms that are less than rigorous and not objective. If Emanuel were to provide an overall ranking, although the US would not be at the bottom, it certainly would not be at the top, either. That honor would go to countries such as Norway and the United Kingdom, where universal coverage is provided.

Emanuel evaluates health systems in the US, Canada, the United Kingdom, Norway, France, Germany, the Netherlands, Switzerland, Australia, Taiwan, and China. These countries were selected because of their diversity in financing methods and their prominent place in health care debates. Wading through the chapters on each country can be quite a chore, but the reader is assisted by succinct summaries at the beginning of each one. Helpful, too, are the consistency of the dimensions used and the chapter conclusions that identify the challenges faced by each country.

Although the US and China are noted as having glaring weaknesses in several areas, no country is without significant challenges. Norway, for example, suffers from a rigid distinction between general practitioners and hospital-based care. This makes care coordination challenging. France could also do a better job of coordinating care, especially for the elderly and people with chronic disease. And although the National Health Service in the United Kingdom enjoys widespread public support, it suffers from staffing shortages, as the number of physicians and nurses has not increased in proportion to the population.

There are, of course, challenges more or less universal to all eleven countries evaluated. Cost pressures related to health care in general and pharmaceuticals in particular are pervasive, and chronic condition treatment and management are generally not optimal. Mental health care continues to be a concern, as countries have transitioned away from institutional to noninstitutional care. Finally, long-term care solutions are spotty even as more countries face aging populations.

Although he might not like to do health care rankings, Emanuel does like to make lists of health policy recommendations and solutions. There are, for example, six lessons for the US. These relate to ensuring universal coverage, covering children at no additional cost to families, simplifying the health care system, emphasizing primary care, adopting best practices for patients with chronic and mental health conditions, and joining the rest of the world in regulating drug prices. Although these seem like common sense, given the continuing political divides in this country, they are not likely to gain traction any time soon. The Affordable Care Act gave the US a toehold in addressing some of these concerns, such as expanding coverage to those previously not insured, but it remains under attack.

Emanuel’s final list, added at the behest of his publisher, is that of tentative thoughts on what the current coronavirus disease 2019 (COVID-19) pandemic reveals about health care systems. Emanuel lauds Taiwan for dealing effectively with the pandemic by proactively identifying people carrying the virus and preparing a stockpile of personal protective equipment. Other thoughts include more rapidly implementing such public health measures as social distancing, contact tracing, and isolating and quarantining of positive cases.

As always, Emanuel provides a thorough and thoughtful evaluation of the topic at hand. Although many readers might not choose to read it cover to cover, this book is a useful resource for those wanting to know the detailed pasts and presents of various health care systems. The lists of recommendations are hard to refute but are, unfortunately, equally hard to implement, given the divisions present in the US. Perhaps someday this will change.