Rating and Evaluating Health Systems: The Value of the Life Expectancy Approach

ABSTRACT

Cross-national ranking and rating of public services does not always provide the conditions for effective cross-national learning, because such learning requires causal understanding of the mechanisms underlying ranking scores. That causal understanding means grappling with the production functions involved in public services, and it is particularly difficult for organizations or policy domains where processes are more readily measurable than outcomes relative to goals. Health is to a large extent a policy domain of that type, which makes effective ranking and comparison difficult and also presents a particular challenge for cross-national learning. Numerous attempts have been made to compare the efficiency of different health care systems, and though there is a certain logic about such approaches to ranking and rating, this paper argues that much can be learnt for health policy using life expectancy as the basis for ranking and comparison.

ACKNOWLEDGEMENTS

I thank Emma Orgeret and Christopher Hood for their English translation of the original version of this paper, and Theodore Marmor and Christopher Hood for their comments, suggestions and editorial advice. I am deeply grateful to the anonymous reviewers for their valuable comments.

Notes

The British figure is 8 for 100,000 inhabitants.

In 1985 alone, when the author was the head of the French hospital system at the Ministry of Health, he got 2,650 political recommendations drawing his attention to particular cases.

France is a country where the suicide rate is high (20 per 100,000 inhabitants per year, compared to only 8 per 100,000 in the United Kingdom or Italy).

This laboratory example illustrates that a sector like health does not have a uniform organizational type. Instead, the claim is that organizations in health/healthcare can be categorized in one of these four types. I owe this qualification to one of the anonymous readers.

For instance, in France, since the reign of King Philip the Fair (1285–1314), every public servant has been considered potentially dishonest. The person who authorizes a payment must therefore not be the same as the person who actually makes that payment, and this rule has become almost universal in public bureaucracies.

For example, in France 100,000 employees of the health insurance organization spend their lives “controlling” the rights to which every legal resident of the country has been entitled since January 1, 2000. The law changed so that it is now simply residence that counts. Before that date the right to health insurance had been linked to employment (meaning that your entitlements depended on whether you were a salaried employee, a farmer or self-employed). All the former controls derived from this employment relation. They still survive because they remain the raison d'õtre of different organizations. But the employment part of the checking system no longer has any operational importance-except to explain to survival of these expensive bureaucracies (costing some 8.4 billion Euro a year).

A phrase coined by one of my colleagues, Claude Riveline, professor at l'école des Mines de Paris.

Robert Fetter was then a professor in the School of Organization and Management at Yale University. Others have explored at length the context in which DRGs have been used, including the extent to which in the American case, as one reviewer noted, DRGs were employed to replace a “reasonable cost” standard of payment and not to measure the impact of hospital care on the health of elderly Americans.

In Knock ou le Triomphe de la Médecine, a famous play by Jules Romains (1923), the main character defines health as “a temporary state between two diseases which doesn't bode well.” A critical view of the WHO definition of health is not new; there are many examples in the literature, as there are many examples of disputes about the degree to which medical care interventions improve a population's health status. For a comprehensive review of those issues, see Evans, Barer, and Marmor, eds. (1994). See also footnotes 15–19 following. This paper addresses the validity of the approaches to measuring health. It does not seek to explain the reasons various approaches have been initiated, though one recognizes that there are many defensible justifications for innovating here, given the multiple dimensions of health, the lack of critical data, and thus the multiple ways by which health or medical care programs and policies could be evaluated. I am indebted to one of the reviewers for clarifying this point.

And life expectancy was 14 years less in 1950.

Computation taking into consideration the 2002 purchasing power parities, source OECD.

Not exactly Russia but USSR.

The population of the United States reached 300 million inhabitants in October 2006.

In his article, Jean-Claude Chesnais notes that in the United States, the homicide rate by “African American” people was 37.5 compared to 5.6 for whites. Violence hits always the weakest.

The number of male births went down from 1.25 million in 1987 to 630,000 in 1999.

Comparisons can also be used to challenge equally entrenched views, such as the commonly believed proposition that people will consume less health care if they have to pay more from their own pocket. Yet if we examine health spending and its rate of growth in different countries since 1990, we find the most expensive and inflationary countries are those in which private insurance plays an important part (United States, Switzerland), or at least a significant one (Germany, France). International comparisons like the demonstration of the fact that tax-financed health systems cost less than those financed by social contributions are potentially very useful in knowing at least what should be avoided. Canada seems to have bravely learnt from that lesson, but big reforms such as those undertaken by that country nearly 30 years ago are few and far between. See Evans, Barer, and Marmor (1994) Ch.8.

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Jean de Kervasdoué

Jean de Kervasdoueis presently a professor of health economics and management at the Conservative National des Arts et Me tiers, in Paris, France. A Cornell University MBA and Ph.D., he has spent his professional life between acadamia (Ecole Polytechique, Paris) government (Under-secretary at the Ministry of Health in France), and the private sector (creator and manager of the largest consulting firm in the health sector in France). He has published 13 books and written more than 200 articles. He is a guest speaker and an expert for many international organizations.