Transformational Change in Health Care

Who is Premier Campbell trying to kid with his junket across Europe for a "study" of health systems? A few minutes at the keyboard would teach him and his fellow travelers more than he is likely to pickup on a taxpayer funded holiday. A good place to start is on the World Health Organization's website.

The WHO publishes an annual "World Health Report", focusing on different topics each year. In 2000 the topic was "health systems" and the report claimed that the French system was best. Of course, ranking health systems requires some form of measurement. The WHO report said: "To assess a health system, one must measure five things: the overall level of health; the distribution of health in the population; the overall level of responsiveness; the distribution of responsiveness; and the distribution of financial contribution." Each of the aggregate measures poses measurement problems. The WHO settled on disability-adjusted life expectancy (DALE) to measure overall level of health. On responsiveness it said: "Responsiveness is not a measure of how the system responds to health needs, which shows up in health outcomes, but of how the system performs relative to non-health aspects, meeting or not meeting a population's expectations of how it should be treated by providers of prevention, care or non-personal services." In other words, the highly controversial issue of wait-times is not included in the WHO report except to the extent that it impacts other indicators. Seven elements were used in a survey to measure responsiveness (numbers in parenthesis are the weights assigned to each element): Respect for dignity (16.7%), Confidentiality (16.7%), Autonomy (16.7%), Prompt attention (20%), Quality of amenities (15%), Access to social support networks (10%) and Choice of provider (5%). The five overall measurements are not necessarily what everyone would choose to compare health systems, and, as shown by responsiveness as an indicator, quantification of the five overall criteria is not simple. The WHO's final rankings added per capita health expenditures and then examined disability-adjusted life expectancy (DALE) relative to available health resources, as well as a measure of all five indicators relative to resources. By this point it should be clear that saying that any country is best is not an unassailable assertion. Canada ranked 12th on DALE but 35th on health level performance (DALE and dollars); we ranked 7th on overall goals, but 35th on overall system performance. In other words, Canada's rankings went down because for the amount of money spent it was assumed that we should have better outcomes. France ranked 3rd on DALE and 4th on health level performance; it ranked 6th on overall goals and 1st on overall system performance. The two countries were side by side on overall goals, 6th and 7th, but 1st and 35th when resources were considered despite Canada ranking 10th on health expenditure per capita and France ranking 4th. That makes it appear that far too much negative propaganda has been generated over Canada's ranking on one aggregate, and somewhat subjective, measure.

Another way for Premier Campbell and others to learn about France's health system, is to simply enter the terms "health care France" in Google. There he would learn that the French system is described as involving "complex processes and rules". One of the first terms that is essential for understanding French health care is "dépassements", not meaning its literal translation of "overtaking of cars; exceeding a limit; or financial overspending" but meaning what Canadians call extra-billing. The FrenchEntrée.com website provides one way of understanding French health care by way of an example of someone involved in a minor bicycle accident who works his way through the system. In the example the cyclist ends up needing a consultation with a specialist and a plaster cast which costs 60 Euros, but the allowed fee (The Tarif de Covention) is 25 Euros and the French public health system pays only 70% of the allowed fee. The percentage paid by the public plan varies by service from 95-100% for childbirth to 35% for some prescribed medicines. Most people have supplementary health insurance to pay the percentage not covered by the public plan, but it is illegal (as it is in Canada, save for the complications of the recent Supreme Court decision) for private insurers to cover public insured services, i.e. to cover the extra-billing.

Some British Columbians are about to get quicker knee and hip surgeries because of wider application of a pilot program that was tested in Richmond, just as some Albertans are benefiting from their experiment with more efficient organization of surgeries. What we have to learn from other jurisdictions may have nothing to do with the hot button topics of user fees, extra-billing and public or private delivery, but everything to do with simple organization of how to make better use of what we already have.