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Comparing Health System Performance In OECD Countries
We present data from the Organization for Economic Cooperation and Development and the World Health Organization on the performance of the health care systems in twenty-nine industrialized countries in 1998. We also compare the performance of the United States with the other industrialized countries for selected indicators in 1960, 1980, and 1998. On most indicators the U.S. relative performance declined since 1960; on none did it improve.
International comparisons of health system data have been used to inform health policy debates for years.1 Tony Blair, for example, recently committed the United Kingdom to increasing its share of gross domestic product (GDP) spent on health care to the average level in Northern Europe. This action was prompted in part by international data showing that the British were spending a lower percentage of GDP on health care than were most other countries in Northern Europe. In the United States, one of the arguments for training more generalist physicians has been international data that showed that the United States trains a higher proportion of specialists than most European countries.2 The Organization for Economic Cooperation and Development (OECD) and the World Health Organization (WHO) have taken the lead in collecting and publishing data for conducting international comparisons in recent years.3 WHO has recently published indicators that monitor health system performance in 191 countries. These indicators measure attainment of three health system goals as defined by WHO: improving health status, responding to people’s expectations, and fairly distributing the financial burden of health care. WHO transformed these indicators into country-by-country performance rankings. These rankings have led to considerable controversy, stemming from philosophical differences about the specific indicators, doubts about the reliability of the data used, and debates over how the various indicators should be weighted. WHO’s World Health Report recognizes the need to refine and improve the data, and careful scrutiny of the country-by-country rankings will no doubt result in refinements to the methodology. Nevertheless, the World Health Report 2000 introduced many innovative and important health system performance concepts and indicators. In this paper we present data from the OECD and WHO on the performance of the health care systems in twenty-nine industrialized countries.4 We focus our comparisons on six subject areas: (1) prevention, (2) health care resources and utilization, (3) medical procedures involving sophisticated technology, (4) mortality, (5) responsiveness, and (6) health spending. This paper is a continuation of an annual series presenting the latest OECD data.5 This is the first year that we present WHO data as well.
Immunization. While by 1998 some OECD countries had achieved nearly universal immunization rates for communicable diseases such as measles and diphtheria, pertussis, and tetanus (DPT), others had immunization rates below 90 percent (Exhibit 1  ). Since 1980 immunization rates have generally been increasing in all twenty-nine OECD countries (data not shown). Interestingly, wealthier OECD countries (measured by GDP per capita) and countries with higher spending per capita on health generally have lower immunization rates than do poorer OECD countries. For example, there is a small negative association between per capita health spending and immunization coverage rates for both DPT and measles (correlation, –.49 for DPT, –.30 for measles).
Although mortality from vaccine-preventable diseases is near all time lows in many developed countries, many unnecessary deaths still occur. For example, WHO estimated that in 1994 more than 20,000 children died from measles in developed countries.6 A variety of methods have been used to increase immunization rates in the United States and other countries.7 Australia, for example, offers cash to parents and doctors and fast-food vouchers to children as incentives. Doctors in the United Kingdom have a financial incentive to reach target immunization coverage levels. In the United States, the state of Georgia raised immunization rates by assessing and providing feedback to immunization clinics; other states also have had success with this approach.8 Despite the availability of proven strategies to increase immunization rates, the United States is currently not on track to achieve the goals outlined in Healthy People 2010.9 The Institute of Medicine (IOM) recently found that instability of funding for state immunization programs, the lack of a comprehensive national-level immunization strategy, and insufficient immunization programs in private health plans were some of the major challenges facing the U.S. immunization system.10
Unhealthy lifestyles.
One aspect of the performance of a health system is the promotion of healthy lifestyles (Exhibit 1
Physicians. The average number of visits per physician per year varies widely across the twenty-nine countries (Exhibit 2 ).12 In 1998 physicians in the median OECD country had an average of 2,167 visits per year; U.S. physicians, 2,222 visits per year. Physicians in Japan and Switzerland had the most visits per year, while physicians in Sweden and Portugal had the fewest. These data suggest that there is great variation in the duration of a physician visit, hours worked per physician, number of support personnel across the twenty-nine countries, but data on these factors are not available.
The average number of annual physician visits per capita also varied widely, from sixteen visits per year in Japan to 1.5 visits in Turkey in 1998. The majority of OECD countries had between five and seven annual physician visits per capita, similar to the U.S. average of six visits per year. Approximately half of the OECD countries had between two and three practicing physicians per 1,000 population in 1998 (the United States had 2.7). There was a wide range of physicians per capita (from 5.9 physicians per 1,000 in Italy to 1.3 in Korea). Surprisingly, there is little statistical correlation (correlation is .06) between the number of practicing physicians in a country and the number of physician visits per capita. Studies conducted in the United States, on the other hand, have shown a high statistical correlation between the two.13 More analysis is needed to reconcile domestic and international studies of the relationship between the number of physicians and physician visits per capita. The United States is close to the OECD median on physician visits per capita, physicians per 1,000, and number of visits per physician. Given that the OECD data show little statistical correlation between numbers of physicians and visits, these data should be evaluated by health professions planners who have used international comparisons to argue that the United States has a surplus of physicians.14 The mix of specialist and generalist physicians also has been a U.S. policy focus. OECD data (not shown) indicate that the United States has a greater proportion of specialists than most other OECD countries have; however, the data are not complete enough to permit a definitive comparison.15
Hospitals.
The number of inpatient acute care hospital days per capita in 1998 ranged from 0.2 days in Mexico to 4.0 days in Japan (Exhibit 2 Since 1980 the U.S. policy focus has centered on keeping people out of the hospital and keeping hospital stays as short as possible. As a result, U.S. hospital use has declined more rapidly than the OECD median: Between 1980 and 1996 the number of inpatient acute days per capita per year declined by an average of 3.3 percent in the United States and 2.7 percent in the median OECD country.17 In 1998 the average length of a hospital stay in the United States was 6.1 days, compared with the OECD median of 7.3 days; the number of admissions per 100,000 U.S. population was 12,492, compared with the OECD median of 13,800. Attention to U.S. hospital spending per day has waned recently. In 1997 it was $1,063 per day, more than twice the level of the median OECD country ($447, data not shown). Real hospital spending per day increased more rapidly in the United States than in the median OECD country between 1980 and 1997 (5.1 percent versus 4.9 percent). Nevertheless, the United States continues to promote a cost containment policy of shorter lengths-of-stay and fewer hospital admissions, rather than lower hospital spending per day. International comparisons suggest that the latter might be more effective. Hospital occupancy rates in 1997 ranged from 59 percent in Turkey to 89 percent in the Netherlands (data not shown). The United States had the second-lowest rate among the OECD countries in 1997—66 percent—far below the 78 percent OECD median (standard deviation, 7 percent). Compared with other countries, the United States has considerable excess capacity in the hospital sector, and recent policy initiatives have done little to decrease this.
High-tech medical equipment. We use magnetic resonance imagers (MRIs) in this paper as a proxy for the availability of expensive medical technology. The number of MRIs permillion persons in 1998 ranged from 0.1 in Mexico to 18.8 in Japan (Exhibit 3 ). The availability of MRIs in the United States was in the upper quartile of OECD countries. Japan, Switzerland, Finland, and Austria had more MRIs per capita than the United States in 1998.
Medical procedures. Comparisons of utilization rates for specific procedures are confounded by differences in the incidence of disease, differences in coding, and many other factors. Nevertheless, there are striking differences in utilization rates for certain procedures across the twenty-nine OECD countries (Exhibit 3  ). Analysis of available data suggests that the United States performs the most or nearly the most procedures per capita in several areas (for example, coronary bypass, more than four times the OECD median).While the incidence of disease and other factors make these figures difficult to interpret, it is unlikely that these factors would explain this fourfold difference.
Disability-adjusted life expectancy is an estimate of the number of years a person will live in full health.18 This indicator was used in the World Health Report 2000 as the summary indicator of the level of population health status because it contains information about both mortality and morbidity. The prevalence of disability is required for its calculation, however, which could lead to comparability problems, since various countries use different definitions of disability.
For women, disability-adjusted life expectancy at birth varied in 1999 from 61.8 years in Turkey to 77.2 years in Japan (Exhibit 4
At age sixty, disability-free life expectancy for women ranged from 15.2 years in Turkey and Korea to 21.7 years in France and, for men, from 11.7 years in Hungary to 17.5 years in Japan. Life expectancy at age sixty averaged four to five years longer in 1998 for both men and women than disability-free life expectancy did. At age sixty, both disability-adjusted life expectancy and life expectancy in the United States were similar to the OECD median. Potential years of life lost (PYLL) measures the years of life lost before age seventy due to preventable conditions.19 As a result, deaths during childhood can have a major influence on PYLL. The United States performs relatively poorly on infant mortality, child mortality, and PYLL (21 percent above the OECD median for men and 34 percent for women) but is similar to the median OECD country on life expectancy and disability-adjusted life expectancy at age sixty. This suggests that a greater focus on infant and child health in the United States may be warranted.
One major innovation in the World Health Report 2000 was the development of an instrument to assess health systems’ responsiveness to the expectations of the populations they serve. WHO delineated seven dimensions of responsiveness: autonomy, confidentiality, dignity, prompt attention, quality of basic amenities, access to social support networks during care, and choice of providers.20 Data were collected by a survey of "key informants" in each of thirty-five countries and imputed for the remaining 156 by multiple regression.21 Among the twenty-nine OECD nations, the United States scored the highest on responsiveness, and Turkey, the lowest. Our analysis shows a strong positive relationship between health spending per capita and the WHO responsiveness score.22 This suggests that additional health care spending may be purchasing greater responsiveness. However, because of the method used by WHO to predict missing data values, this finding may overstate the relationship between spending and responsiveness.23
Spending per capita. The United States continues to spend considerably more per capita on health care than any other country —more than double the amount spent by the median OECD country in 1998 (Exhibit 5 ).24 We performed two comparisons to place this higher health spending in context.
First, studies have shown that most of the difference in health spending across countries can be explained by the level of average wealth, as measured by GDP per capita.25 Countries with higher average wealth spend proportionally more on health care. Taking the average wealth of U.S. citizens into account, the expected level of U.S. health spending is $2,868 per capita.26 This is still $1,310 less than the amount actually spent per person in the United States. Multiplied by the approximately 281 million Americans, this represents additional spending of approximately $370 billion. Second, if the United States spent the same amount on health as Switzerland ($2,794 per person), the country with the second-highest per capita spending in 1998, then U.S. health spending would decline by almost $400 billion per year.
Health spending growth.
During the period 1960–1998 the rate of increase in real health care spending in the United States was slightly below the rate of increase in the median OECD country (Exhibit 5 Between 1960 and 1998 there was some tendency toward regression to the mean in health spending. Countries with high health care spending per capita in 1960 tended to have slower rates of spending growth than did countries with lower spending per capita.29 Countries with more rapid economic growth also had more rapid increases in health spending.30
Since the number of countries reporting data varies by indicator and year, the relative ranking is expressed as the percentile rank of the United States compared with the other OECD countries reporting data in that year (Exhibit 6 ).31 A percentile rank of 100 is given to the country with the highest value for each indicator, except for infant mortality, potential years of life lost, and alcohol consumption, where a percentile rank of 100 is given to the country with the lowest value.
For no indicators did the relative performance of the United States improve from 1960 to 1998. Indicators for which the United States showed the greatest relative decline were life expectancy at birth for females, life expectancy at age sixty for females, and infant mortality. The relative number of practicing physicians and the number of acute hospital beds per capita declined. Health spending per capita remained consistently high. Potential years of life lost remained consistently low, and life expectancy for males at birth and at age sixty and alcohol intake remained in the mid-range of OECD countries. Policy makers are most interested in determining whether additional health care spending will result in better outcomes. Countries offer natural experiments that could suggest whether an investment in a certain area has resulted in better outcomes in that country. Unfortunately, the availability of outcome indicators that can be used to compare the performance of health care systems is sparse. A concerted effort to increase the number of indicators that can be used to compare the performance of health care systems across countries should be a priority of the international community. Particular attention should be given to quality of-care indicators. Policymakers want to know how the billions of dollars spent on hospitals, physicians, pharmaceuticals, and other health services translates to improvements in health status for their populations. Comparable international data are needed to conduct these comparisons.
Jerry Anderson and Peter Hussey are with the Johns Hopkins School of Hygiene and Public Health, Department of Health Policy and Management, in Baltimore, Maryland. An earlier version of this paper was presented at the Commonwealth Fund International Symposium on Health Care Policy, "Quality and Innovation: Issues, Strategies, and Implications for Policy," in Washington, D.C., 11–13 October 2000. The analysis was sponsored by the Commonwealth Fund.
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